119 Holly Hill Ct Lot 18 {{ .xdi1
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'f,3Ii[O .IQATION No: 1.480JD
'DAVIE COUNTY HEALTH DEPARTMENT
-Environmental Health Section PROPERTY.INFORMATION
Permittees_ P.O:Box 848.
Name: c ���� Mocksville,NC 27028 Subdivision Name: i
Phone#:704-634-8760
Directions to property: tC'G>, fp S/ a r /` Section: Lot:
AUTHORIZATION FOR ��� _
WASTEWATER Tax Office PIN.# f
SYSTEM CONSTRUCTION
Road Name: Pr
**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 11 of G.S.Chapter 130A,Wastewater Systems,Section:1900 Sewage Treatment and Disposal Systems)
L t r J ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
00
IS VALID FOR A-PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
DAME COUNTY HEALTH DEPARTMENTo
ryes IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Subdivision Name: 1�", ' 1 ""
Directiods to property: ' tt r''r�f s" Section: .r I.ot /i
IMPROVEMENT P"'� r
Tax Office PIN:#� .�.�`� '
Road Name: F C°,OP�P..�_� -74
ru
**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 I3OA,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
*** ***
• ,Y,,.�• �!���,� / � NOTICE THLS 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_� #BEDROOMS�_#BATHS�r _#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYP #PEOPLE #PE�3PLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY el-1,6 DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE�e GAL: -PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH _ LINEAR FT.-?4*r'
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(704)634-8760.
OPERATION PERMIT
SYSTEMINSTALLEDBY:
40
1 ArdV_ �1 v'e--
lt'
Ho�S�
F
AUTHORIZATION NO. 1 OPERA ON PERMIT BY: DATE: g
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY M DESCRIBED OVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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.
DCHD 05/96(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI
Davie County Health Department up �p
Environmental Health Section rJU8 h7op
P.O.Box 848
Mocksville NC 27028
( 3 6)751-87
ENVIRONMENTAL HEALTO
DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE
//REQUIRED
-7IIN�FORMATION IS PROVIDED.��
1 /�iVO
Name to be Billed ,� CI28 04)C61j3T.-1-/V C . Contact Person
Mailing Address o7a S UJIN6- A4(,/4:-il/ Lit/. Home Phone - 7S 7`l
City/State/Zip '&OC,-S ✓/C LC . C 7U a Business Phone R /c1'U-7d.7 q
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation Cl Improvement Permit&ATC O Both
4. System to Serve: House O Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _ # Bathrooms
AI Dishwasher Garbage Disposal X Washing Machine ❑ Basement/Plumbing ❑ 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: Ix County/City ❑ Well O Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLA MTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: AT P4,q / eG/Y CC.-o.ScO 1 WRITE DIRECTIONS(from
_ 1 Mocksville)TO PROPERTY:
Tax Office PIN: # 5 7 g - - k •S% 1
1 /SS Tv
Property Address: Road Name
rD 40A -
City/Zip Ao✓A44e (/ C_ a-7oo '
' TLt�ZAJ Lt=r- p,V
1
If in Subdivision provide information,as follows: 1
1 K
Name: InA"eCH 600,1o-s 1
1 mrcEa
Section: Lot #: Ae '
k DAY /0-.
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 WQC2 T'5, to conduct all testing procedures
as necessary to determine the site suitability. �7
DATE SIGNATURE
Revised DCHD(06-96)
YOU AIAJ USE THE BACK OF THIS FORAt FOR DRAWING YOUR SITE PLAN. I PP
V.
SIDNEY F. HOOTS /
D.B. 175 Pg. 507
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34
1.4
NOTES /
1. ALL LOTS ARE SUBJECT TO DAVIE COUNTY
,���� �/ �/ ` /'/•��� / /i// /' /�-"��i/ /�' / i I r !! ,' / HEALTH DEPARTMENT STANDW2DS.
2. ROADS ARE TO BE BUILT TO NCDOT STANDARDS
BEING A PUBLIC ROAD WITH A 60' RIGHT-OF-WAY
,. /zi