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453 Ijames Church RdOPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Kevin Nunn Address: 1448 Liberty Ch Rd City: Mocksville StatefZip: NC 27028 Phone# (336) 751-6180 Property Location le- Address/Road #: Subdivision: Off Ijames Church Rd Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC *IP Issued by. 2140 - Nations, Robert *CA issued by: 2140 - Nations, Robert Design Flow: 3 6 0 Soil Application Rate: 0 2 7 5 N krifwcation' Field No. Drain lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: C f rui volae use vmv *CDP File Number 187847-1 G3-000-00-024-08 County ID Number. Evaluated For. NEW Township: Property Owner. Lary Bass Address: 453 Ijames Church Rd CRY: Mocksville State/Zip NC 27028 Phone # (336) 624-.6773 Phase: Lot: Directions Hwy 601 North left on Ijames Church rd. On Left beside 410 Ijames Church Rd *System Classification/Description: TYPE IIA CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? OYes OQ No *Distribution Type: GRAVITY- PARALLEL (eq. d -box) Pump Required? OYes ONo *Pre Treatment: 1 3 0 9 sq. ft. 5 3 2 7 ft. 9 _Inches O.C. (&Feet O.C. _ 3 6 @ Inches oFeet inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer. Randy Miller Certification #: 1128 *EH S: 2325 - Mitchell, Brittany Date: 0 7/ 2 7 /.2 01 5 Minimum Trench Depth: Inches Minimum Soil Cover. = Approval Status Inches Maximum Trench Depth: Inches ; ®approved_D Dlsappi Maximum Soil Cover: Inches CDP File Number 187847 - '1, Countv ID Number: G3'0o0'-00-024-os Manufacturer: Shoaf STB: 760 Gallons: 1000 Dosing Volume:. Date: 0 4/ a 1/ a 0 1 5 "Filter Brand: Yes ❑ No ST Marker. ❑: Yes ❑ No Reinforced Tank: ❑ Yes ❑ No ,,-,,,piece Tank: ❑ Yes ❑ No Manufactures AUC TanK Pump Tank PT: Gallons: Randy Miller Dosing Volume:. Date: Gal Certification #: 1128 RiserSealed ❑ Yes ❑ No RiserHe"ght: ❑ Yes ❑ ,NO, (Min.6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Pipe Size: 4 inch diameter Pipe Length: 3 feet `Schedule: 40 Pressure Rated ❑ Yes ❑ NO' Approved fittings ❑ Yes ❑ No Installer. Randy Miller Certification #: 1128 1EH S: Date: �� t=�Appravaf Steius ° O Approved ❑ Disapproved Supply Line Installer: Randy Miller Certification #: 1128 `EH S: 2325 - Mitchell, Brittany Date: 0 7 / a 7 / a 0 1 5 / Pump Type: / Installer: Randy Miller Dosing Volume:. — Gal Certification #: 1128 Draw Down: Inches 'EH S: "Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check valve ❑ Yes ❑ NO a ' Approval Stott PVC unions .❑ Yes ❑ No ❑, Approved ❑ Di Vent Hole ❑ Yes ❑ No Anti -siphon Hole 0 Yes ❑ No CDP File Number 187847-1 Electric Ea NEMA 4X Box or Equivalent ❑ Yes ❑ NO Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No Pump Manually Operable ❑ Yes ❑ No *Activation Method: County ID Number: G3 -0o0-00-024-08 ment Installer: Randy Miller Certification #: 1128 *EH S: Date: Alarm Audible El Yes ❑ No Approval Status 0iDisapproved, Alarm Visible ❑ Yes ❑ No 2325 - Mitchell, Brittany *Operation Permit completed by: Authorized State Agent - Date of Issue: 0 7 2 7 2 0 1 5 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 TYPE a A sewage septic system. Rule .1961 requires that a Type TYPE n A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection)M aintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type 1V and V septic systems designed for a homelbusiness owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a public managemententitywiih a certified operatorforthe life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity priorto the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 187847 - 1 Davie County Health Department CDP File Number: 210 Hospital Street G3-000-00-024-08 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 07 / a7 / 2 0 1 5 1 A Olnch Drawing Drawing Type: Operation Permit Scale: , OON/Ack ................ ........... J VA El s (31 +' LLI -1 1 1 LLL I i _ I _ 2e 1 n Tax Map: Address: Installer: EHS: a Operation Permit Inspection Checklist Location and Separation Distances 1. Distance from septic tank/pump tank to foundation/basement. 2. Distance from system to well if applicable 3. Any other setback (.1950) requirements 0 Supply line 1. Material supply line is constructed of !}. HD diameter_ 2. Length of supply line (2' min.) 3' 3. Amount of fall in supply line (1/8" per foot min) 4. Distance from ST/PT to the nitrification field/dist. device) Septic Tank/Pump Tank 1. Visually inspect top of tanks(s), interior & exterior walls, baffle wall and bottom 2. Any honeycombing or exposed rebar present? Circle : YES or NO 3. Visually inspect sanitary tee, lids, and air vent for proper installation and sealant 4. Tank Serial Numbers: STB -7(p 0 PT 5. ST Win 6" finished grade? Circle: YES or NO 6. Date of manufacture: ST 4/1-1 PT 7. Liquid capacity of tanks ST 1,00 0 PT 8. Effluent filter type 9. Pipe penetration seal present? Circle: YES or NO 10. Riser(s) present? Circle: YES or No Riser Type 11. Pump Tank riser 6" above finished grade? Circle: YES or NO 12. Riser approved? Circle: YES or NO feet feet inches feet Nitrification Field 1. Septic Tank outlet elevation 2. Trench Depth Readings (inches) 3. Number of Trenches Distance between trenches 4. Trench Width 5. Aggregate material type and size 3 4 5 6 57 (Circle) 6. Aggregate Depth (inches) 7. Nitrification lines installed on contour? Circle: YES or NO 8. Innovative system type Installer certified for installation? Circle: YES or NO 9. 2' earthen dam between ST (or d -box) and beginning of nitrification line? Circle: YES or NO 10. Stepdowns a. b. C. d. e. 2' undisturbed earthen dam(s) Circle: YES or NO Proper rise over stepdowns? Circle: YES or NO Solid pipe used? Solid, Corrugated or other? Elevation of each stepdown Are all stepdowns lower than the ST outlet elevations? Distribution Devices 1. Type 2. Distance from Dist. device to trenches_ 3. Record elevations: Inlets Is the device watertight?, Outlets Circle: YES or NO Is it level? feet - CONSTRUCTION For:office:Use only. a 4 AUTHORIZATION"CDP File Number 187.847:-1 .40 Davie County Health Department C6unty1D Number. G3-000-00-02408 210 Hospital Street Evaluated For:. NEW It .��,. P.O. Box 848 Township: Design Flow: 3 6 0- Mocksville NC 27028 PERMIT VALID UNTIL: 6 Phone: 336-753-6780 Fax: 336-753-1680 0 1/ 1 8/ a 0 a 0 Applicant: Kevin Nunn PropertyOwner: Larry Bass Address: 1448 Liberty Ch Rd Address: 453 Ijames Church Rd City: Mocksville City: Mocksville State0p: NC 27028 State2lp: NC 27028 Phone #: {336} 75.1-61$Q Phone #: {336} 624-6773 Property Location 8Site Information AddresslRoad #: Subdivision: Phase: Lot: Off Ijames Church Rd Mocksville NC 27028 Directions Hwy 601 North left on Ijames Church rd. On Left beside Structure: SINGLE FAMILY 419 Ijames Church Rd # of Bedrooms: 3 4 of People: 'Water suppiy: PUBLIC *Proposed System:25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 0 0 @ Gallons J 1 -Piece: Oyes *No. Pump Required: ( Yes @No OMay Be Required 1 3 0 9 Sq. ft. Pump Tank: Gallons 3 1-Piece:OYes ONo 3 a 7 GPM vs— ft. TDH 9@FeetO.C. Inches O.C. Dosing Volume: _ Gallons Inches 3 Feet Grease Trap: Gallons inches Pre Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV Dcknn 9 of Q Minimum Trench Depth: a 4 � Inches Site Classification: Provisionally Suitable Saprolite System? OYes ®No Minimum Soil Cover. 1 a Inches Design Flow: 3 6 0- Maximum Trench Depth: a 6 Inches Soil Application Rate: 0 - 1 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: "Distribution Type: GRAVITY - PARALLEL (eq.d-box) TYPE U A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) I $antic Tank' *Proposed System:25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 0 0 @ Gallons J 1 -Piece: Oyes *No. Pump Required: ( Yes @No OMay Be Required 1 3 0 9 Sq. ft. Pump Tank: Gallons 3 1-Piece:OYes ONo 3 a 7 GPM vs— ft. TDH 9@FeetO.C. Inches O.C. Dosing Volume: _ Gallons Inches 3 Feet Grease Trap: Gallons inches Pre Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01 Oil 0111 OIV Dcknn 9 of Q CONSTRUCTION AUTHORIZATION Davle County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 187847 -1 County File Number: G3 -000 -00 -024 -00 - Date: 01 / 18 / 20 15 Olnch Scale: .OBlock QN/A 0 9_ CDP File Number 187847-1 County ID Number. G3-000400-024-08 ❑ Open Pump System Sheet fired: "W Tey %-)140 VIVO, Dui rld5 HVd1ldDle �irdl:C ■�yMM....,.,...... Trench Spacing: QInches 0. 9 *Site Classification: Provisionally Suitable — ## Feet O.C. Trench Width: 0 Inches 3 Design Flow: 3 6 0 .- , * Feet Aggregate Depth: Soil Application Rate: 0 - 1 7 5 inches Minimum Trench Depth: a Inches *System Classification/Description: TYPE [IA. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches *Proposed Maximum Trench Depth: 3 6 Inches System: 25%REDUCTION Maximum Soil Cover. a 4 Nitrification Field 1 3 0 9 Sq. #t. _ _ Inches No. Drain Lines *Distribution Type: GRAVITY -SERIAL 3 Total Trench Length: '3 2 7 Pump Required: [QYes @No (May Be Required ft 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*ofthis 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. ; This Authorization forWastewater System Construction shall bevalld for a person equal to the period of validity of the improvement Penn% not to exdeed five years, and may be issued atthe sametime the improvement Permit issued (NCGS 13OA-336(b)). if the Installation has not been completed during the period of ttatidlty of the Constriction Pennit, the information submitted In the application fora 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 maybe suspended or revoked (.1937(8)). 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 (1930(b)). Applicant/Legal Reps. Signature Required? OYes ONO Applicant/Legal Reps. Signature; Date: , 1 `Issued By; 2140 - Nations, Robert Authorized State Age Date of Issue:. . / , 1 �. / 5 Malfunction Log Oyes OHand Drawing 01mport Drawing **Site Plan/Drawing attached.** Page 2 of 3 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health d1 P.O. Box 848/210 Hospital Street 9a�; r PC� Mocksville, NC 27028 c wpb (336)753-6780/ Fax (336)753-1680 Rte° �� Application For: ❑ Site Evaluation/Improvement Permit uthorization To Construct (ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name v. k V113 Contact Person Addressyu_koc, Home Phone City/State/ZIP k-�(_ '(oaf Business Phone 7-15 1 - C. l% Email \0A�no�tv.��a�.�.����rac Name on Permit/ TC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flaaaed % — g -/ r NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name \.•L kT,_\� Phor, ❑Plat(to scale) Number Owner's Address +­5�s t City/State/Zip Property Address OCC- i City Lot Size Qcrt5 Tax PIN# G 3- 000- UUSubdivision Name(if applicable)___,n, Section/J,ot# To Pro IF RESIDENCE FILL OUT THE BOX BELOW �,c a—[Oa 0-0-o8 # People '-.)- # Bedrooms -3 # Bathrooms Garden Tub/Whirlpool ❑Yes []No Basement: PYe-s ❑No Basement Plumbing: �s ❑No 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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other, unty/City Water ❑New Well ❑Existing Well ❑Community Well Water Supply Type: R<o- Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 corners and locating and flagging or staking the hese/facilocation, 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 # U -7gq Revised 11/06 _ Invoice # _ Davie County, Environmental Health P.O. Box 848/210 Hospital Street - Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 99000575 `�� Tax PIN/EH #: G30000002408 Billed To: Day' orris ✓ Subdivision Info: Address: 8 Hwy 158 Location/Address: Ijames Church Road -27028 City: Mocksville Property Size:. 8.14 Acres Reference Name: Propo"&Pity §qA� &ent Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article l l of G.S. Chapter 130A,.Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: QNew ❑Repair ❑Expansion Permit Valid for: V Years ❑No Expiration Residential Specifications: # Bedrooms— W # Bathrooms 2` # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):!kL0__ Type of Water Supply: County/City ❑ Well ❑ Community Well Site Modifications/Permit Conditions: System Type LTAR Initial 2so o Q ' Repair 2_ Site Plan Ax- 1 � Environmental Health Specialist i.p.11-06 Date_ a ff �....J a��S �-1�vv�c.� �� 08/08/2011 08:45 FAX 8. 2011 1t:47AM 'PtuJenti'al Carolinas Realty No. 31bti r, 1002 ` APPLICATION FOR S><'TL•' EVALUATION/IMPROVEMEI4T PERMIT Davie County Envllronwental Health .4 4% 11.0. Box 1/148/210 Hospital Skoog t, 160 MooluV111o, NC 27028 n /, �hj (336)713-6780/ rxx (336)75;1-1,6$0 'Al`(U W Application For: O'$its F.! aiGati n mprovcanent Permit O Authorization To Construct (ATC) oth Typrs of Applicatioc._ -ONaw System 014spair w llxlatiag Systum opaipansioTiaAadiftcation of axisting System or Fa t •••IMPOR �CANNOTBEPROCESS1rD UNLESS ALL OFTXM�"QUIRED INFURMA"�S"PK6V�IDED. Refer to tht INFOitMAT101K HULLE I [1J !or inatrucNons. APPLICANT INFORMA"1TUN . i 1Vaine a 0, Contact Person at/(°1 x4or-c'cs Nddress 5' Home Phone City/State/ZIP 13u2iueea Phone A& d4 ` Name on eettnit/ATC ifDEf itrent than Above NOTE: A purvey plat or sits Platt tmst acoompaxty thin applicatioc. Included: M Site Piot oplat(*o *Cate) (Penl7pit is -olid for 60 onoulba'skith site P n iratiori with complete plat.) Owner'sNatae _ 1 , % i -R�.i` MonaNumbct Ownar's Address Ciry/Stare/Zip Property Address City_, OpUU062. Lot Size �.i� _ Tax PINIt vt.JV Subdivision Name(if ruble) S tionll.o it /-i Directions To Site- � — , ��^ , .t . I !�` .... _ %�/ /!,•,/ U'I lfthe answer to any of the foliovving queetiooa is•"Yes' pyorting docurrtentadon must Are ttme any existing wastewater systems on the site? ,_Yes tj�No Does the site contsin)tuisdietional wetlands? Yes ZNo Are there any casements or right of -ways on the site?Yes No Is the site subject to approval by another public agency? _��''NYes 'o Will w"tcwater other than domestic sewage be generated? _ Yes !,�No ff People 9— # Bedrobwt l# Bathrooms 'J Garden Tub/Whirlpool ❑Ycs b,No I Baaertrent: OYeu jallo ldaaeme t Plumbi ❑Yes Myo Type of Faclitty/Business Total Square Footage ofBuildina # People " .— # Sinker _ # Commodes . 0 Showers # Urinals Estimated Water Usage (gallons per day) _. , `(Attach documentation of similar facility water consumption) FOODSERv1C8 ONLY: # Seats Typc system requested: Ykionventional. OAoeepted Olnnovative OAltarnativa• 00thcr Water Supply •Iypn- '�Cottnty/City Water O New Well OExisting Well n Community Well Do you anticipate, additions or expansions ofthe facility this system is latendod to serve? O Yea No Ifyes. what type? .,-- This is to sonify that the information provided on this application is LLLLe and oorrect to Wte best of my knowledge. I tmderntand that any permit(*) or ATC(s) issued hereattor ary subject to euapcnslon Or rcvooetion if the site is alterod, the Intended use changes, or if the infbrmation subrnirted in this appllest(oo is rauffied nr changed. I bereby plant right of entry to the Authorized Represontative of the Davie County krcalth 0cpwrttnertt to conduct neocssary inspections to determine, compllartce with applicable Iowa end rs I s I understand that I ata re&ponaible for the proper Identification and labeling of property lions and corners and oc ing ■ging or stakin the bo eOfac111ry location, proposed well location and the location of any othor am utitieA. �'r trey wp or owner a e rr rd Site Revisit Charge le /' ClientNotdi—tion Drtta' _ pacer .. — 1✓li5- Sign gxvon Oyes ONOActwuni y Revised 11/06 SEP 16 2011 t! Invoice # 4, 4ok-01 EBI� _k q81Z Y , TI R SITE EVALUATION/IMPROVEMENT PERMIT & ATC D r Davie County Environmental Health SEp 1 201 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 vlR4t�MENjPt N �jN _ (336)751=8760/ Fax (336)751-8786 EI`1 , nF C�iJ; u ca ' ri Mite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Billing Address _ City/State/ZIP Name on Permit/ATC if Different than Above. Mailing Address PROPERTY INFORMATION Contact Person _ Home Phone _ Business Phone *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is v id for 60 montlivyith site plan, no expiration with complete plat.) Owner's NamePhone Number ' Owner's Address City/State/Zip Property Addre City Lot Size I Tax PIN# .5—Y'.2-010 Subdivision Name(if applicable) Sectiondot# / Directions To Site: 0 If the answer to any of &e following questions is "yes", supportingocumentation must be attached. Are there any existing wastewater systems on the site? ❑YeskNo Does the site contain jurisdictional wetlands? ❑Yes 26o Are there any easements or right-of-ways on the site? ❑Yes Plo Is the site subject to approval by another public agency? ❑YesGNo Will wastewater other than domestic sewage be generated? ❑Yes DkNo rW 1M IF RESIDENCE FILL OUT THE BOX B LOW # People # Bedrooms —# Bathrooms ?/Garden Tub/Whirlpool Wes ONO Basement:,�Ycs ONO Basement Plumbing: es ONO 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:. ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other 41: 5 "o Water Supplx Type:�ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? X -No 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 corners and locating and flagging or staking the house/facility ]pcatio� proposed well location and the location of any other amenities. owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given ❑Yes ❑No Account # L-7DZp Revised 11/06 Invoice # GoMAPS - Davie County NC Public Access Page 1 of 1 A- Davie County, NC - GIS/Mapping System 4P`a9s� Ct ( Click Here To Start Over, Quick Search: (County ID c pi �l Active Layer. r Use Map Tips GIS PARCELS (Map Tips Available) iw= ---- Map Layers I Results I Of 0 0 104j� -"'"' ... 72 334 ' I � 114 41Q0 04 TJAMEs::CHO Z 1 4534 54437443a 423m / 403 ) 335 "`343R84CO 325 34 1p 41 35"p- �xhy fin! �hhtj " ry 4 8S ii00 0 333 `317 A3 ' t.,.R�S?2322 / 0 04 001 � 104 S4_ 41 94( tin140,1— . '141 CO v 4 d0� 29.3 173 146 47.01 335.71 LIS 02$9.7 ft 19D http://maps.co.davie.nc.usIGoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=412... 9/10/2007 GoMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System OP�s fry Click Here To Start Over Quick Search: (County ID c + r I �L Active Layer. F Use A7ap 7rps GIs ,oPPARCELS (Map Tips Available) Man Lagers i Results 1 http://maps.co.davie.nc.usIGoMapslmap/Index.cf n?mainmapservice=gomaps&CFID=412... 9/12/2007 GgMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC GIS/Mapping System Qa�V� Click Here To Start Over Quick Search:(County ID c Active Layer. Use Map Vps GIs �U tib �' x . Q PARCELS (Map Tips Available) i' Map Layers Results _� DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/ Site Evaluation - APPLIC cc T IN) OIIMATIQI�T Tax PIN/EH #: 58g� INFORMATION Billed To. Jeff Hayes Subdivision Info: Reference Name: Location/Address: Ijames Church Proposed Facility: Residence Property Size: 8 Acres' Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring x Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % a HORIZON I DEPTH Texture group C Consistence Structure Mineralogy;1 HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION p5 LONG-TERM ACCEPTANCE RATE] SITE CLASSIFICATION: EVALUATION BY: l LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam , L - Loam SI - Silt SICL Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay . C Clay CONSISTENCE Moist VFR - Very friable FR Friable FI - Firm VFI - Very firm EFI - Extremely firm Wa NS - Non sticky SS - Slightly sticky S - Sticky VS -Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK -Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed lYat� Horizon depth - In inches Depth of fill - In inches Restrictive horizon Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Reviser]) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT D Lam' !? C Davie County Health Department . Q � Environmental Health Section OCr I �^ L P; 0. Box . 848/210 Hospital Street 8 71 Mocksville, NC 27028 v 5� °��{, �� (336)751-8760. ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. . ctions 1. Name to be Billed Perso���T c.+(�j� 41W W �Qt,rre.�c'� o va'la..f Mailing Address Home Phone �q. �•" /��p (1C(w�C,� ne City/State/ZIP /Phone'" 2. Name on Permit/ATC ��If�� Different than Above Mailing Address"//14D Clemn=<City/State/Zip �� ' W ! a 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ❑ House )6 Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: # People # Bedrooms # Bathrooms �. YDishwasher KGarbage..Disposal tXWashing Machine 11 Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Indus \ try/Other: Specify type #People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type oflIwater supply: ❑ County/City ❑ Well ❑ Community s. _Do you anticipate additions or expansions of the facility this system is intended to serve? M Yes ❑ No If yes, what type?, GaLe p_ J• C",- 5-�-na j ***IM'PQRTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. PropertyDi I ensions: 1fL \ AC._.la WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: 115'�110 1 O �-O Property Address: Road Named—`f1UrC�) nn,, j �S C.Vnh L. City/Zip U-� "0Q- omcwp� ((xA WO-1Ico If in a Subdivision provide information, as follows: of n Y\Iaq onopi �es ICS nZZ_, Name: pf2S'} �I'�. �c� w� r 'l I 1 Section: Block: Lot: Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that 1 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Poe Count- Health pepartment to enter upon above described property located in Davie County an ed by WaQ `ii to conduct all testing procedures as necessary to determine the site ita ility. DATE L O I �i SIGNATURE ` THIS AREA MAY BE E USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge y Date(s): Client Notification Date: EHS• Z,sJ Y1 Account No. Revised DCHD (07/99) Invoice No. 100 30 172 0 100 "-- __ too 1330/ November 01,199911:07 AM DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soij WEval Vuation APPLICANT INFORMATION Account M 990000895 Billed To: Delbert Bennett Reference Name: Rachel Maxime Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH M 5820-10-8950 Subdivision Info: Forest Brook Lot # Location/Address: Ijames Church a -27 8 Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring V Pit Cut SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: • �� OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H.- Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 'Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed .. Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less , Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) position HORIZON I DEPTH ConsistenceLandscape HORIZON MEMO Texture . , . iAKsMU-Na■ormW1. � Mineralogy HORIZON Ill DEPTH .• . • ���®owe Texture - MGM Mineralogy • I KIN SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: • �� OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H.- Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 'Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed .. Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less , Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) r i r, r aij APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health DepartTpnt Environmental Health 5 v P.O. Box 848/210 Hospital S Mocksville, NC 27028 (336)751-8760 OCT 9 ZL� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED INFORMATION IS PROVIDED. Refer to the INFORMATION Bl 1. Name to be Billed Mailing Address v City/state/ZIP 2. Name on Permit/ATC if Mailing Address Contact PersonFi7/dl ley Home Phone �Oz Business Phone than Above 3. Application For: Ili Eite Evaluation City/state/Zip ❑ Improvement Permit/ATC ❑ Both a. system to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry 61Othew�f�/h 5. If Residence: # People. J # Bedrooms / # Bathrooms 17 Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats 1Estimated Water Usage (gallons per day) / 7. Type of water supply: IIf County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes A' -No If yes, what type? '"IMPORTANT"* CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 7✓, # I cies Tax Office PIN: 1 Property Address: Road Name V City/Zip If in a Subdivi ion provide inforpiation as follows: . P xe�e.471 Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: &4 WZ 0 Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. 1, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Da ' County Hea Depart to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site sui ability. DATE /!D'/�%c'/Of/(� SIGNATURE61 !U THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. Invoice No. /330J 5440 1 I 16490 18309 9396 18 L,17 8 SCale:l" _ •�� (814A) 8950 264.011 15 November 01,199911:07 AM i FGIEA U4( ITE EVALUATION/IMPROVEMENT PERMIT & ATC ' Davie County Environmental Health SEp 0 2001 P.O. Box 848/210 Hospital Street 1 f d Mocksville, NC 27028 ' 117 2 (336)751-8760/ Fax (336)751-8786 EPMRONM 1JTAL HEALTH A ovement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION IF RESIDENCE FILL OUT THE BOX B LOW # People # Bedrooms _.�) # Bathrooms Z�'Garden Tub/Whirlpool es ONO Basement: Nes ONO Basement Plumbing: Xes ONO IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building# People I' P # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:. ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Zs—/ L Water Supply Type:)!�tounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes o 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 staking the housee//ffa,acil�cation proposed well location and the location of any other amenities. /1/.. .ov7�P,;1/'o-'owner's legal representative signature P /PI Sign given Dyes ONO Revised 11/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # QZ70 �0_ Invoice # _U/ Name to be Billed IG'I�G ' Contact Person Billing Address Home Phone City/State/ZIP usiness Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A'survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit i ali for 60 with site lan, no expiration with complete plat.) Owner's Name_.&,Z � �� Phone Number �* Owner's Address City/State/Zip PropertyAddre - City Lot Size Tax PIN# Subdivision Name( if applic le) Sectio ot# /'r _ 11 Directions To Site:. c If the answer.to any of de following questions is "yes", supportin ocumentation must be attached. Are there any existing wastewater systems on the site? ❑Yes.�io Does the site contain jurisdictional wetlands? Dyes no Are there any easements or right-of-ways on the site? Dyes J�Wo Is the site subject to approval by another public agency? ❑Yes GNo - Will -wastewater other than domestic sewage be generated? ❑Yes�do IF RESIDENCE FILL OUT THE BOX B LOW # People # Bedrooms _.�) # Bathrooms Z�'Garden Tub/Whirlpool es ONO Basement: Nes ONO Basement Plumbing: Xes ONO IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building# People I' P # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:. ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Zs—/ L Water Supply Type:)!�tounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes o 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 staking the housee//ffa,acil�cation proposed well location and the location of any other amenities. /1/.. .ov7�P,;1/'o-'owner's legal representative signature P /PI Sign given Dyes ONO Revised 11/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # QZ70 �0_ Invoice # _U/ GoMPS = Davie County k Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System Click Here To Start Over Quick Search:(County ID c E Active Layer rv-j use Map 7Fps FIs ° PARCELS (Map Tips Available) Map Layers Results I a 'GOV709 IDG {.: '= '= _72 334 ` typo rTJAh19. HU ) s PPO 335 RCii it© =- a .._ a� .. f 847_ 4534 45 437J 6442122 sn 1 4f1343954 34 fp35,p2 �� 5 9�. 359,E 4 4 85 LUQ.4 333 01317 Q QUO liT0104.5 4194 I�N 140a — r?� 73 44d S3 n47 a3 _ 335,71 J+ s 289.7 ft 19D • GoMAPS - Davie County NC Public Access Page 1 of 1 0-� Davie County, NC - GIS/Mapping System 3 Click Here To Start Over Quick Search: (County ID c Wf Active Lager. r Use Map Tips GIs o� �. Piap Layers Results i PARCELS (Iulap Tips Available) ... � L. i 5 - ! 0-� GoMAPS - Davie County, NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System Click Here To Start Over Quick Search: (County ID t u Active Layer.. E Use. Map 71ps pis t E4 4;;; P, t PARCELS (Map Tips Available) I Map Layers I Results, 370 134! 12 1U - _ 296 11A ._. rnn �,r err- {//,r t f { � r t01 http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=412... 9/12/2007. APPLICANT INFORMATION Account :.99000 Billed To: `Jeff Hayes Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section .r Soil/ Site Evaluation Tax PIN/EH #: 5SZU_ 1U=8�- FORMATION Subdivision Info: Location/Address: Ijames ChurchX9T 8 Property Size: 8 Acres . Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Bbring / Pit Cut • ®®©QO� Landscape position HORIZON I DEPTH Texture group Consistenceralp !��s�r�s����s� HORIZON H DEPTH AUANKL Texture group Consistence LOWAY ROM M_ sn"FRm- Oman Mineralogy HORIZON III DEPTH Texture group Consistence Structure HORIZON IV DEPTH Texture • ..Consistence Structure —MineralogySOIL WETNESS RESTRICTIVE HORIZON CLASS _ _, SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ©� "� OTHER(S) PRESENT: REMARKS: �. V i3l .� \ " �� 1 • Q if v - LEGEND Landscape Position R - Ridge S -Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood.plain H - Head slope Texture S -Sand LS 7 Loamy sand , SL - Sandy loam L - Loam SI - Silt SICL - Silty clay koam SIL -Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C -Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - $(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/0.5 (Revicerll ■■■■■■■ ■■■■■■■ ■■■■■■■ ■ ■ ■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■tl■lir■■■■■■■/■/■■ ■■ ■ w ■■ ■ GoNWS - Davie County NC -Public Access Page 1 of 1 http://maps.co.davie.nc.us/GoMaps/map/print.cfm?CFID=4141&CFTOKEN=64238063 9/21/2007 Account M 990002706 Billed To: Jeff Hayes Address: 130 Hwy 801 S City: Advance Reference Name: Proposed Facility: Residence M Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 .(336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Tax PIN/EH #: 5820-10-8950.02 Subdivision Info: Location/Address: Ijames Church Road -27028 Property Size: 1/2 of 8 Acres **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with . Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: /rNew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms —S # Bathrooms 2J # People Basement❑ Basement plumbing 1, Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3iCO Site Modifications/Permit Conditions: site X Q 1� Type of Water Supplyi�County/City ❑Well ❑Community Well c-�� � M System Type LTAR Initial /) - 47!;- Repair %Re air �t�tT1AL ZSfj REPo,1{,� Environmental Health Specialist Date O :_ii_nA