110 Lost Farm Drive Lot 28 DAVIE COUNTY HEALTH DEPARTMENT ,
• Environmental Health Section C 9
P.O:Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001316 Tax PIN/EH#: 5880-51-4715
Billed To: Craig Carter Builders, Inc. Subdivision Info: Magnolia Acres Lot#28
Reference Name: Location/Address: Lost Farm Drive-27006
Proposed Facility: Residence Property Size: 298 x 218
**NOTE *This Improvement/Operation Permit DOES NOT authorize the construction 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). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People_ #Bedrooms #Baths
Dishwasher Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow(GPD) N�Vd Site: New❑ Repair❑
System Specifications: Tank Size GAL. Pump Tank GAL. Tr ch Widt Rock Dept" Linear F�
Other: APAav-,�--v� P
(YA&
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Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LA OU AP ROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a r esen tilt' ROVE
Davie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to . 0 p o the day of installation. Telephone#is(336)751-8760.****
l�
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001316 Tax PIN/EH#: 5880-51-4715
Billed To: Craig Carter Builders, Inc. Subdivision Info: Magnolia Acres Lot#28
Reference Name: Location/Address: Lost Farm Drive-27006
ATC Number: 3707
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: Date:
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 mi W WAY be taken as a guarantee that the system will function satisfactorily for any
given period of t'ri .
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
' CATION I OIi S17L CVALUATION/IMPRUVL-JIICM'1'L'Iti1�Il'I'&A•I'C a
•MAR 1 .2004 Davie County Health Department
Environinenta/Hea/f/1 SeCM04f
M1ENT�100 P.O. Box 848/210 Hospital Street
ER�NECpBNTY rlocksville, NC 27028
(336)751-8760
***XMPORTANT*** TIiIS APPLICATION CANNOT B2 PROCESSED UNLESS ALL THE REQUIRED I
1 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed (_ �aZ / l�-e� P ,offr Contact Person (7—'<C_C �_•.,. .
Mailing Address Q' TJ�_ .fie+ S , home Phone
City/State/ZIP ��V�i,st�G G iiG'•C �O Business Phone _ `^ro
2. Hama on Permit/ATC if Different than Above
Mailing Address �\ G City/Stat./Zip -;I-
3. Application For: ❑ Site Evaluation A Improvement Permit/ATC ❑ 130E-1
4. System to Service. 19 House ❑ Xobile Home ❑ Business ❑ Industry ❑ othcr
5. Type system. requested: ❑ Conventional .eX conventional modified ❑ innovative
6. If Residence: It People _ 11 Bedrooms �_ II Bathroontu c�'Dishwasher Aarbago DisposalIfflWashing Machina [baseman /PltunbingIlasement/lto Plumbing
7. If Dusin.ns/Industry /Other: verify type 0 People I1 Sinlcs
# Commodos U Showers 1f Urinals 11 Water Coolers
IF FOODSERVICE: ## Seats Estimated Water Usage (gallons per day)
a. .Type of water supply:X County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this systcltl is itltended to serve?❑yes XfNu
` If yes,what type?
***Ihll'ORTziNl***CLIENTS MUST COIll'LL•'TL•'TIIE 1�QUIRGD 1'KOI'EK'1'1'iNFOIt114A'i'ION 1tISQl1E5'1'Ia)
BELOW. Eitltera PLAT orSITE PLAN HUSTBESU114fITTED by the client tiviU,'1'IIIS AI'PI,ICA'I'ION.
Property Dilncnsions: IYRI'I'E ll1KLC1'IUNS(front 1llocl;svillc) U, I'ItUI'I;It'1'1':
Tax Office 1'IN: ## - "V71 :5PropertyAddress. RoadNamc �: -M - a � B S/I'7���•�-S�
City/Zip 7d D L z�4-
If in a Subdivision provide infurnlation,as follows: aZ 1 - S4
Namc: l// �d�r -'J7 G jr S f ti 'V7 OL 1 '4
Section: �_ Block: _ Lot: Date !ionic corners flagged: - 6
This is to certify that the information provided is correct to the best ofu y C1 11011-Ic(Igc It Ji i slall�f l it :tl:uly perillit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if tits iuforam(ion
submitted in this application is falsilled or changed. 1,also,understand that l um responsible fur all charges incurred frun,
this applicatlun. I,hereb)-,give consent to the Authorized Representative of tate Davie County IIealllt DeparUueut
to enter upon above described property located in Davie County and owned by _
to conduct all testing procedures as necessary to deterininc the site suitability.
DATE
TIiIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the fullowing: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit C(t:u•gt:
Client Notification Date:
EIIS. ,
hl >
Sign given �' Accot6 t No. ( /
Revised DCIID(05/03 _ _ rnvotee', 0 3
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LOST FARM DRIVE g
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LOST FARM 86°54'40"E 218.00' ot
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I r SITE PLAN ONLY
CI 2B THIS WAS MAPPED FROM A DEED OR
I �I RECORD PLAT AND NOT FROM A SURVEY
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( ' 40 0 40 80 120
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IGRAPHIC SCALE — FEET
MAP CRAIG CARTER BUILDER INC.
15' UTILITY 4 DRAINAGE EASEMENT FO R
SCALE TOWNSHIP COUNTY STATE DATE.s
N 86°29'33"W 1" = 40' SHADY GROVE DAVIE N. C. 3-10-04
223.00'
LOT 28 MAGNOLIA ACRES PHASE 2
I 19 HOWARD SURVEYING JOB N0.
JOHN RICHARD HOWARD PLS 04012
P.O. BOX 276 ADVANCE, N.C. (336) 998-5396