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1653 Jericho Church Rd (2)r " AUTH0114ZATION NO: a DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section PROPERTY INF©RivIA"1'TON Permittee" s P.O. Box 848 a�o Name: �GE'cc.—I `* Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 Directions to property: �t-l� t( Section: Lot: AUTHORIZATION FOR �l"�� FhS��1?� WASTEWATER lTax Office PIN:# - SYSTEM CONSTRUCTION 0 ..,� Road Islame:3xLi- ' IIV N 140 Zip: ^x702 **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. _._ENV11�0 N- HEAL > C(Al ISTt DATE SS' hED r. j t DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS Permitfee's Nacre' Directions to property: � t t. i F IMPROVEMENT PERMIT PROPERTY INFORMATION110 .L 0 Subdivision Name: r Section: Lot: Tax Office PIN:# Road Name: :: i' ; t s Zip. **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST` " } DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE / INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 0J5G# BEDROOMS _� # BATHS I # OCCUPANTS —_:5— GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFFI�IC'CATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE! ,TYPE WATER SUPPLY fl Y DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE r SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ._>� _� ROCK DEPTH 12 LINEAR FT. Jy ` l L,1�Jr s 1 10. 0. rv1W OTHER 71ST 1 L Crt0►h 1-,c5 TALI- ►vS REQUIRED SITE MODIFICATIONS/CONDITIONS: ! �.J K ! 1. �l c-� k �.1 �i �1 �-� .1 IMPROVEMENT PERMIT LAYOUTcAPPRDUED 'EFFLUEUT FILTER* *RISER(S) IF 6" EE'LMI FI?146ISHED GRADE r l -T�, -1 Y o N r\ 00 "CONTACT "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY, HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) fa34: &7.6f X (336)751-8760 OPERATION PERMIT SYSTEM INSTALLED BY:^� I W t L-4� «► �• SCl-l() Q�Q�� —' Nor 14SITALa i sZ, J r'sw 35x3���r2'' N -TH LS t.t►J� '�o SAS i AUTHORIZATION NO. 9/4 OPERATION PERMIT B DATE: r "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA TH DESCRIBED�TEMS"A,B�UT BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) � L SYSTEM INSTALLED BY:^� I W t L-4� «► �• SCl-l() Q�Q�� —' Nor 14SITALa i sZ, J r'sw 35x3���r2'' N -TH LS t.t►J� '�o SAS i AUTHORIZATION NO. 9/4 OPERATION PERMIT B DATE: r "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA TH DESCRIBED�TEMS"A,B�UT BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department VIF Envir+vnmenta/Hea/th SectionP.O. Box 848/210 Hospital Street 52 Mocksville, NC 27028 (336)7 51-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED------ INFORMATION EQUIRED"'--=---INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �Fi2 l7 ' �fZ� Contact Person 460ia Mailing Address der/e, Aa ,ac/V �v' ' Home Phone %, --� City/State/ZIP ��OC,�S ///LLC /`" \ Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation 4. System to Service: FA.House ❑ Mobile Home 5. If Residence: # People City/State/Zip improvement Permit/ATC ❑ Business ❑ Industry ❑ Other # Bedrooms 3 # Bathrooms _ I ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Dishwasher ❑ Garbage Disposal X Washing Machine 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 4 County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ,WNo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # ,f 7.7- -7 15; li — ! Property Address: Road Name /,�S Jr )er, PAo C.4. 9/ city/zip/-'-Z 6,45-y' Ile- . If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date Property Flagged: Ez:�� 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 I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by /C o 6Cr=T e2� to conduct all testing procedures as necessary to determine the site suitability. DATE S'/� 2, SIGNATURE 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). reek S6s3 P�rs,�G -Z' vs1/G c Lige' � ;rXiaV/c Revised DCHD (07/99) o YRS o /"1 Ac- S N° NCLr-k- v- a f 0 w 641�- Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. c Invoice No. ��- � _ � Y �g �iq+f,C n � x}yq�°"��✓t +- vs nK AA IV ya Yy � X��� Y ys i t1E is t }� 1662 v"'s" a: 'i �v} ♦ �"" � P� i � `` JI � a}3d E 1�� 14 Ef} 1 Y I q H i n J4r��rjP 1fidf�' j! i fit} x ya "A }r}f i, - O. � �-7C 1-71 (-q s 143 .. 1 1 74 Account #: Billed To: Reference Name: Proposed Facility: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 990001032 Tax PIN/EH #: 5727-94-3619 r Robert Erb Subdivision Info: Robert & Kathy Erb Location/Address: Jericho Church Road -27028 Residence Property Size: 3.5 Acres ATC Number: 2360 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:c AA ' // ba�r?� Date: --22 -a) CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99 (Revised) r-2v�•� l_t�-cam -t-� 3-L,0 Date: