106 Holly Hill Ct Lot 23 -.- F,r+r-r.r = .. ...•.. r...,.a � r..c. ..r.. •s..; •c 1 r:v aw ..y.•,,. .�-�. . r*+: eYw+
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Ai rt R1ZATiON NO:, 1666 DAVIE C LINTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's�rC�, , . f,��/ P.O.'B'ox 848
Name: ' Kf L i/ G'l "d. Mocksville;NC 27028,,'. Subdivision Name:
/ Phone# 336-7M-8760
Directions to`property: d',/ : / .f . �r Section: Lot:
AUTHORIZATION FOR ,e
WASTEWATER Tax Office PIN:# --�� .
SYSTEM CONSTRUCTION eC�..+
Road Name: i.:Zip: Q�
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building-PenT ts.,This Form/Authorization Number should be presented to the Davie CountyBuilding Inspections
Office when applying for Building Permits..
(In compliancewith Article 1 I of G.S.,Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
-
***NOTICE*** AUTHORIZATION FOR WASTEWATER CONSTRUCTION
a '�-r
.� 'r '�S IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED:
-t...�,,:. b(�
`�/
�f a ,? } 'dry^.iw" W!�• U`'L Z•'I i P
1666 DAVIE.C OUNTY HEALTH DEPARTMENT
TMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Perpnittae's
Ata Subdivision Name:
=' =
j
Directions to property: Section: ,� Lot: t
IMPROVEMENT
i PERMI! Tax Office PIN: - •
` Road Name
**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
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST 'DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE�L_ #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY .DESIGN WASTEWATER FLOW(GPD) NEW SITE Lam- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/ GAL. PUMP TANK GAL. TRENCH WIDTH (ROCK DEPTH LINEAR FT.c9, 66
I OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT,
"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 (336)751-8760.
OPERATION PE IT
SYSTEM INSTALLED BY:
ry
b
AUTHORIZATION NO. ` OPERATION PERMIT BY: L DATE:
"TETE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
'LEI
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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DOM 05/96(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&
Davie County Health Department
Environmental Health Section JUN _ 8 '
P.O. Box 848 M
Mocksville NC 27028
( 3 6 j7 7G0 ENVI D VIE 1/
ITALTH m ffi,,
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE/REQUIRED INFORMATION IS�iVPROVIDED.
��_&& /�.t/n
1. Name to be Billed _AC& OC/28 0•(��au.S%. �NC . Contact Person ..../C. t7/ e$O�
Mailing Address c,?Q S WIN& 491/�-A1 LA/. Home Phone ' 7S 77
City/State/Zip �/RoC&S ✓!u ,C . Al.C .270 z Business Phone 3-3�/9qB-7a7`I
2. Name on Permit/ATC if Different than Above
Mailing Address City/Strrl i,9
Pto
3. Application For: Site Evaluation improvement Permit&ATC ❑ Both
4, System to Serve: House ❑ Mobile Home O Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _,3 # Bathrooms
ADishwasher Garbage Disposal Washing Machine ❑ Basement/Plumbing O Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: X County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLATOR THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: R�97— doe e / eg/Y CC_0.Sc0 1 WRITE DIRECTIONS(from
Mocksville)TO PROPERTY:
Tax Office PIN: # 7 e a/ - 'Z 6- - i 9' .5-
% 1
/SS Tv
Property Address: Road Name
/2Try 4,QVA-1VQ_=
City/Zip AOt/A ,cE_ /tLC d-700 G 1
1 7&...-W Lf=r (nn/
1
If in Subdivision provide information,as follows:
1 K
Name: 1"A'e cq w00z)S 1
114, min
Section: Lot #: Z 3 1
GU DW 2r .
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.1,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 &O—C)T'z' to conduct all testing procedures
as necessary to determine thesitesuitability. �7
DATE 6 7 SIGNATURE ke—J Z)
Revised DCHD(06-96) �� a
JOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. ,
SIDNEY F. HOOTS /
D.B. 175 Pg. 507 / Ike
N 33.47'22,
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00
75 Pg. 504 e / LOy 7-
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504
/
NOTES
1. ALL ARE SUBJECT TO DAVIE COUNTY
HEALTH DEPARTMENT STANDARDS.
2. ROADS ARE TO BE BUI"