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1963 Angell Rd Davie County,NC Tax Parcel Report Tuesday, February 21, 2017 'tit 015 "� 1978 1991 / 5 194? r 1920 1951 __ `-1929 I I 1903 WARNING: THIS IS NOT A SURVEY Parcd Information Parcel Number: E30000008201 Township: Clarksville NCPIN Number: 5821524549 Municipality: Account Number: 8305899 Census Tract: 37059-801 Listed Owner 1: KELLY TODD ALLEN Voting Precinct: CLARKSVILLE Mailing Address 1: 105 WILLOW TRACE CIRCLE#5 Planning Jurisdiction: Davie County City: CLEMMONS Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27012 Voluntary Ag.District: No Legal Description: 4.034 AC ANGELL RD Fire Response District: WILLIAM R.DAVIE Assessed Acreage: 3.87 Elementary School Zone: WILLIAM R DAVIE Deed Date: 12/2015 Middle School Zone: NORTH DAVIE Deed Book/Page: 010070714 Soil Types: PcC2,CeB2 Plat Book: 12 Flood Zone: Plat Page: 132 Watershed Overlay: DAVIE COUNTY Building Value: 126040.00 Outbuilding&Extra 0.00 Freatures Value: Land Value: 30600.00 Total Market Value: 156640.00 Total Assessed Value: 156640.00 AMIE All data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS webslte shall hold harmless the County of Davis,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to t'OUN� NC or arising out of the use or Inability to use the GIS data provided by this website. OPERATION PERMIT or fice U se Only Davie County Health Department *CDP Fite Number 219385-1 210 Hospital Street 5821525526 P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Carolina Custom Homes of Property owner: Todd Allen Kelly Address: 2450 N Church St Address: 105 Wiilowtrace Circle City: Burlington City: Clemmons State/Zip: NC 27217 StatefZip: NC 27012 Phone#: (828)421-9130 Phone#: (817)514-8633 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Angell Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North to Angell Road on right #of Bedrooms: 3 #of People: *Water Supply: PUBLIC *IP Issued by. 2t40-Nations,Robert *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140.Nations,Robert Sapral'rteSystem? QYes GNo Design Flow: 3 6 0 "Oi5t GRAVITY-SERIAL Pump Required? ribution Type: O Yes G No Soil Application Rate: 0 a 3 5 *Pre Treatment: Drain field 14 deification Field 1 3 0 9 S4. 8• *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 3 installer: Jimmy Cobb Total Trench Length: 3 a 6 ft. Certification#: 2696 Trench Spacing: 9 Inches O.C. — ()Inches O.C. *EH S: 2140-Nation,Robert Trench Width: - 3 ( Inches Date: 0 9 / a 1 / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Inches Ap`provat Status' Maximum Trench Depth: 3 6 ®,Approved LD Disapproved Inches Maximum Soil Cover 1 4 Inches CDP File Number 219385 - 1 County ID Number: 21525526 Septic Tank Manufacturer. Shoaf Lat. : , STB: 760 Long Gallons: 1000 Installer. Jimmy Cobb Certification#: 2696 Date: t3 7 / 0 7 / 4 6 1 6 *EH S: 2140-Nations,Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes F*1 No Date: 0 9 / 2 1 / 2 0 1 6 Reinforced Tank: El Yes ® No Approval Status = 1 Piece Tank- ❑ Yes C7 Na ® Approved El Dtsapproved Pump Tank Manufacturer Installer PT: Certification#: Gallons: *EHS: Date: / / Date. Riser Sealed ❑ Yes ❑ No RiserHeght ❑ Yes ❑ No (Min.6 in.) ApptnvaI Status einforced Tank: ❑ Yes ❑ No ❑ Approved❑ Dtsapproved 1 Piece Tank: ❑ Yes ❑ NO Supply line Pipe Size: inch diameter Installer. Pipe Length: feet Certification : *Schedule: *EH S: Pressure Rated ❑ Yes ❑ No Date: Approved fittings [I Yes 11N 0 Approval Status £© Approved❑ Dtsapproved Pump e Pump Type: installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ N o Check-valve ❑ Yes ❑ NaApprovalYStatus PVC Unions E] Yes El No ❑ A; ; D' C:1 Dtsapprovetl Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes 0 NO t CDP Fite Number 219385 - 1 County ID Number: 5821525526 Electric Equipment NE �4X or Equivalent ❑ Yes ❑ No Installer Box 12 inches Above Grade ❑ Yes ❑ No Certification : Box Adj. Pump Tank ❑ yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No Approved❑ Disapproved Alarm Visible ❑ Yes � ❑ NO _ 2140-Nations,Robert 'Operation Permit completed by: Authorized State Agent: Date of Issue: 0 9 / 1 / x 0 1 6 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for .Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a rVPE 11 A. sewage septic system. Rule.1961 requires that a Type: TYPE II A. septic system meet the following criteria: Minimum System Review By The Local Health Department: WA _ Management Entity: OWNER Minimum System InspectioniM aintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator. N/A Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract_ _ with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of en Operation Permit for a system required to be maintained bya public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing 41mport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 2193 f - 1 i Davie County Health department CDP.File Number: 210 Hospital Street 5821525526 P.O.Box 848 County File Number: Mocksville, NC 27028 Date: Q Inch Dr-awing Drawing Type: Operation Permit Scale: . ON A k ! I I I a� ,Ady, -el_m� j E f _ 6 r CONSTRUCTION For office use on►v ' AUTHORIZATION *CDP File Number 219385-1 Davie Count Health Department 5821525526 Y P County ID Number: 210 Hospital Street Evaluated For: NEW •tea•; ,,. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 6 / a 8 / a 0 a 1 Applicant: Carolina Custom Homes of Property Owner: Todd Allen Kelly Address: 2450 N Church St Address: 105 Willowtrace Circle City: Burlington City: Clemmons State/Zip: NC 27217 State/Zip: NC 27012 Phone#: (828)421-9130 ):� Phone#: (817)514-8633 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Angell Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North to Angell Road on right #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: 4 rSaprolite lassification: Provisionally suitable Inches Minimum Soil Cover: System? OYes No Inches esgn Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: 3 a 7 ft GPM--vs— ft. TDH Trench Spacing: — 9 O Inches O.C. ®Feet O.C. Dosing Volume: Gallons Trench Width: — 3 OInches �1 AFeet Grease Trap: Gallons inches Pre-Treatment: O NSF OTS-1 O TS-II Aggregate Depth: Septic Tank Installer Grade Level Required: 01011 O III 01V Page 1 of 3 CDP File Number 219385 - 1 County ID Number: 5821525526 ❑ Open Pump System Sheet Repair System Required:(&Yes O No O No, but has Available Space CDesign System Inches O. . Trench Spacing: 9 O ification: Provisionally suitable — ®Feet O.C. Trench Width: R Inches w: 3 6 0 _ 3 Feet Soil Application Rate: 0 a Aggregate Depth:7 5 inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 LESS) oZ Inches Maximum Trench Depth: 3 6 *Proposed System: 25%REDUCTION Inches Maximum Soil Cover: .1 4 Nitrification Field 1 3 0 9 Sq.ft. Inches No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 a 7 ft .Pump Required: Oyes ®No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R�abing 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. R� i 9 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the Information submitted in the application for a permit or Construction Authorization is found to have been incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes ONO Applicant/Legal Reps. Signature- Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 6 a 8 a 0 1 6 Authorized State Agent: Malfunction Log OYes ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 219385 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5821525526 P.O.Box 848 County File Number: Mocksville _ NC 27028 Date: 06 / ,28 / .2016 O Inch Drawing Drawing Type: Construction Authorization Scale: . . O Block O N/A ................,.................,..................:................................ ..................................................................... ................................................................................................................................................................................:_................. ,.......:....:.. f ............................... ............1. ........ !....._ i ......... - ....1. .. ._ ...........I } .I ..... ....... I. 1. ...... 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I...... ....... ........ i.. I....... . .. . ....._ ............................ . ....... ................................... ........ } I i ..........1. 1.... ..........._G................ .......... ..... . f ...... L.. I I i I 1 i I....... �- ..... .....a i ................. I' � LI ........... ..... I , I........... 1 ' I i _.... �....%j .. I............... ................. ........ . ...... ...._ . ......... ' I t ........ i... i . .. ....::........ . -::r:r ................. ... ..... ....... ....I............. ........' . ... .. I ........ Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street ��'r ��- Lo CDP File Number: 219385 - 1 P.O.Box 848 5821525526 Mocks 'Ile `® NC 27028ef // County File Number: �`o �.�1 b y .�.. ` Date:^0.6./ .a.s. /.a.0.1.6. Click below to import an image from an external locat- n: Drawing Type:Construction Authorization 3 (0 �0 IN 60 r � 5 V(0 y^\ Page 3 of 3 P1 P2 CONSTRUCTION r For Office Use Only AUTHORIZATION ti�`�� *CDP,File Number 219385-1 Davie County Health Department �� County ID Number:021525526 210 Hospital Street Evaluated For. NEW ., ,. P.O. Box 8480 Township: Mocksville NC 2 028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 6 / a 8 / _ a 0 .a . 1 Applicant: Carolina Custom Homes of Property Owner: Todd Allen Kelly Burlington Address: 2450 N Church St Address: 105 Willowtrace Circle City: Burlington City: Clemmons -- State2ip: NC 27217 StatefZip: NC 27012 ` Phone#: (828)421-9130. Phone#: (817)514-8633 Property Location & Site Information FAddress/Road #: Subdivision: Phase: Lot: ll Road sville NC 27028 Directions Structure: 'SINGLEFAM ILY Hwy 601 North to Angell Road on right #of Bedrooms: 3 #of People: 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: a (Design lassification: Provisionauy suitable Inches Minimum Soil Cover. te System? OYes QNo `1 - a Inches Flow` 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVrTY-SERIAL TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 _ Gallons *Proposed System: 25%REDUCTION 1-Piece: OYes QNo Pump Required: OYes QNo OMay Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing: _ 9 WInchese t O C.O.0 Dosing Volume: Gallons Trench Width: _ 3 Olnches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: O N SF OTS-I OTS-II Septic Tank InstallerGrade Level Required: OI OII O III OIV Dann 1 of Q CDP File Number 219385 - 1 County ID Number: 582152552E3 ❑ Open Pump System Sheet Repair System Required:@Yes ()No ONO, but has Available Space resign System Trench Spacing: 9 Q Inches O.C. ification: Provisionally Suitable — Feet O.C. Trench Width: 0 inches w: 3 .6 — 3 (�Feet Soil Application Rate: 0 - a 7 5 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 *Proposed System: 25%REDUCTION Inches Maximum Soil Cover: a 4 Nitrification Field 1 3 9 Inches No. Drain Lines"" � � `Distribution Type: GRAVITY-SERIAL 3 __.. Total Trench Length: 3 a Pump Required: Oyes @No OMay Be Required.., - Pre Treatment: ONSF OTS-1 OTS-11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; This Authorization for wastewater system Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be Issued at the same time the Improvement Permit issued(NCGS 130A-336(b)�If the installation has not been completed during the period of validity of the Construction Penn it,the information submitted In the application for a permit or Construction Authorization is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? OYes ONO Applicant/Legal Reps.Signature? Date:_ *Issued By: 2140-Nations,Robert Date of Issue: 0 6 / a 8 / a 0 1 6 - Authorized State Agent: Malfunction Log OYes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 219385- 1 Davie County Health Department CDP File Number: 210 Hospital Street 5821525526 P.O.sox 848 County File Number: Mocksville NC 27028 Date: 0 6 / 2 8 / 2 0 1 6 Q Inch - - Drawing Drawing Type: Construction Authorization Scale: , pslock QNIA L-111-T F _-I � � l j. I _ CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 219385 - 1 P.O.Box 848 5821525526 Mocksville NC 27028 County File Number: Date: _0 .6 / 28 / 2 0 1 6 Click below to import an Image from an external location: Drawing Type:Construction Authorization For Office Use Only IMPROVEMENT PERMIT *CDP Fite Number 219385. 1 Davie County Health Department 210 Hospital Street County ID Number 5821525526 Evaluated For. NEW P.O. Box 848 Mocksville NC 27028 Township Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 6/28/2021 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Carolina Custom Homes of Property owner: Todd Allen Kelly Address: 2450 N Church St Address: 105 Willowtrace Circle City: Burlington City: Clemmons State/Zip: NC 27217 State2ip: NC 27012 - Phone#: (828)421-9130 Phone#: (817)514-8633 Property Location & Site Information rMocAngell ss/Road #: Subdivision: Phase: Lot: Road ksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 North to Angell Road on right #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications nitial System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches SaproliteSystem? OYes ONo Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 2 7 5 1-Piece: OYes ONo Pump Required: OYes 0 N OMay Be Required *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: OYes O N o Repair System Required:(&�Yes ONo ONO, but has Available Space Repair System *Site Classification: Provisionally suitable Minimum Trench Depth: 2 4 Inches Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes @ No O Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 219385 - 1 County ID Number: 5821525526 *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit by the Health Department in noway guarantees the issuance of other permits.The permit holder- -- is responsible:for checking with appropriate governing bodies in meeting their requirements. , The Improvement Permit shall be valid for 5 years from date of issue with a site pian(means a drawing not necessarily drawn to Site Plan . scale that shows the existing and proposed property lines with dimensions,the location of the faality and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale of one inch equals no more than 60 feet,that Includes:the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale). The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article This permit is subject to revocation If the site plan,plat,or intended use changes(NCGS 130A335(f)).The person owning or controlling the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring, reporting,and repair(.1938(b)} Applicant/Legal Reps.Signature Required? OYes ONO Applicant/Legal Reps.Signature; Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 6 / a 8 / a 0 1 6 Authorized State Agent: OValid without Expiration? 0Create CA. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 219385 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5821525526 P.O.Box Bas County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: OBlock QN/A _ _ ft; 77[�� I�-- r r-- I �J t-A I ! l I I I I � , n... n _'r IMPROVEMENT PERMIT ' Davie County Health Department 210 Hospital Street CDP File Number: 219385" 1 P.O.Box$4$ 5$21525526 Mocksville NC 2702$ County File Number: Date: 06 / 2 $ / 2016 Click below to import an Image from an external location:Drawing Type: Improvement Permit APPLICATION FOR SITE EVALUATIONM"ROVEMENT PERMIT&ATC Davie County Environmental Health �1 P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For. �te Evaluation/improvement Permit Gift orization To Construct(ATC) 1Both Type of Application: P'New System ❑Repair to Existing System EExpansion/Modification of Existing System or Facility IMPORTANT'THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name C'f114otrovACyiftow &Yryef 6"Lra�e:nr+ Contact Person P/>fUIC /lal(lEitTlOr.► Address 7(4f*n/. CHvetW tT• Home Phone?ag—yah-q/30 City/State/ZIP Business Phone 3 36-Za6-Q06 Email PAut �.CO^ Email: S*A." Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged 512&114 NOTE: A survey plat or site plan must accompany this application. Included:0 Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name 704P#9Z41Fr/KF[e y& wrft Phone Numberb'/7-S/tf-8673 Owner's Address_IOrwXZfOW772AcECLkCCt- City/State/ZipC(C s/ivZ-a�o/a. Property Address Lo I o9wJFLC.RD. City�tt(E- Lot Size J/•03Y AW,( Tax PIN# rr.7/. Subdivision Name(if applicable) /N9 Section/Lot# Directions To Site: If the answer to any of the following questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? _Yes W14o i Does the site contain jurisdictional wetlands? Yes ✓leo Are there any easements or right-of-ways on the site? Yes &-No Is the site subject to approval by another public agency? _Yes I/iffo Will wastewater other than domestic sewage be generated? Yes W90 IF RESIDENCE FILL OUT THE BOX BELOW #People 3 #Bedrooms 3 #Bathrooms 2 Garden Tub/Whirlpool❑Yes 8No Basement:❑Yes i No Basement Plumbing: ❑Yes C� IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: Seats Type system requested: eo-,n entional ❑Accepted ❑Inn�ative []Alternative ❑Other Water Supply Type:Ltr C, my/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes wfro- If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or s the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given [-,Yes❑No Account# Revised 11/06 Invoice#