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133 Primrose Rd Lot 2 4 OOERATION PERMIT or ice use n v Davie County Health Department *CDP File Number 137837- 1 aid rt'meqq 210 Hospital Street tiB P.O. Box 848 County ID Number: •'�~''' Mocksville NC 27028 Evaluated For: NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Dick Anderson r perty Owner: Dick Anderson Address: 225 Winghaven Lane ress: 225 Winghaven Lane City: Mocksville y: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)492-7579 Phone#: (336)492-7579 Property Location & Site Information Address/Road#: Subdivision: Marchwoods Phase: Lot: 2 133 Primrose Advance NC 27006 Directions Structure: SINGLE FAMILY 1-40 to Hey 801 go south, turn left on peoplescreek, turn right Old March, tum left on march ferry the tum #of Bedrooms: 3 left on primrose #of People: *Water Supply: PUBLIC *IP Issued by. *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert SaproliteSystem? OYes QNo Design Flow: 3 6 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required? OYes ONo Soil Application Rate: 0 .2 7 5 *Pre Treatment: Drain field rNo. ion Field 1 3 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD n Lines 4 Installer. brianmodaniel Total Trench Length: 3 2 7 ft. Certification#: Trench Spacing: — 9 ginches O.C. Feet O.C. EH S: 2140-Nations,Robert Trench Width: 3 Qlnches OFeet Date: 1 0 / 1 6 / .2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 a Inches Minimum Soil Cover 2 0 Inches Approval Status Maximum Trench Depth: 3 6 Inches CFO] proved n Disapproved Maximum Soil Cover: 2 4 Inches CDP File Number 137837 -•1 County ID Number: _ Septic Tank Manufacturer. shoal Let. STB: 760 Long: - Gallons: 1000 Installer: brian mcdaniel Date: 0 8 / 1 a / a 0 1 4 Certification#: 'EHS: 2140-Nations,Robert *Filter Brand: Date: 1 0 / 1 6 / 2 0 1 4 ST Marker. El Yes [D NO - - Reinforced Tank: ❑ Yes [D NO Approval Status 1 Piece Tank: ❑ YeS D No Approved❑ Disapproved Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: 'EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status R7170, ced Tank: El Yes 13 No Q Approved❑ Disapproved iece Tank: ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: 'EH S: 'Schedule: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No Approval Status ❑ Approved❑ Disapproved Pump e ui e e t Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches THS: 'Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ NO Approval Status PVC unions ❑ Yes ❑ No ❑ Approved 1 Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 NO CDP File Number 13837 -' 1 County ID Number: Electric Equipment NEMA 4X Box or Equivalent El Yes El No Installer: Box 12 inches Above Grade ElYes ❑ No Box Adj.To Pump Tank ElYes ❑ NO Certification#: Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Approval Status Alarm Audible El Yes ❑ No ❑ Approved❑ Disapproved Alar Visible E] Yes ❑ No 2140-Nations,Robert *Operation Permit completed by: dif> Authorized State Agent: Date of Issue: 1 0 / 1 6 / 2 0 1 4 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 11 A. sewage septic system. Rule.1961 requires that a Type TYPE ll A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator. WA Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed fora horne/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to 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 for maintenance 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. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 137837 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Operation Permit Scale: , ON ABlock ft. 7_7 00 �_ _ _ 1 ►� ( U l l� I � ► � I _l 1.�_ ! 1 !�- i � i I 1 _ l-_ _l _►_ -ice__i �1 -66NSTRUCTION For office use only AUTHORIZATION CDP File Number 137837-1 Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: NEW .l ,,. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 4 / 3 0 / 2 0 1 9 Applicant: Dick Anderson Property Owner: Dick Anderson Address: 225 Winghaven Lane Address: 225 Winghaven Lane City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: �(336)492-7579 Phone#: (336)492-7579 Property Location & Site Information Address/Road#: Subdivision: Marchwoods Phase: Lot: 2 133 Primrose Advance NC 27006 Directions Structure: SINGLE FAMILY 1-40 to Hey 801 go south, turn left on peoplescreek, turn right Old March,turn left on march ferry the turn left on #of Bedrooms: 3 primrose #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesign ification: Provisionally suitable Inches Minimum Soil Cover: 1 a ystem? OYes XNo Inches w: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 x 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: OYes ®No O May Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: 3 .01 7GPM--vs— ft. TDH ft. Trench Spacing: Inches O.C. 9 Feet O.C. Dosing Volume: Gallons Trench Width: 3 Inches Feet Grease Trap: Gallons inches Pre-Treatment: O NSF OTS-1 OTS-II Aggregate Depth: Septic Tank Installer Grade Level Required: 01011 O III 01V Page 1 of 3 CDP File Number 137837 - 1 , County ID Number: ❑ Open Pump System Sheet Repair System Required:0Yes ONO ONO, but has Available Space CDesign System Trench Spacing: 9 O Inches O.C. fication: Provisionally suitable — ®Feet O.C. Trench Width: Inches w: 3 6 0 _ 3 Feet Soil Application Rate: 0 a 7 5 Aggregate Depth: inches u *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: LESS) 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 3 0 g Sq.ft. Maximum Soil Cover: a 4 Inches No.Drain Lines 3 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 3 a 7 ft Pump Required: OYes ®No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R'n' Home must be plumbed to rear.The front cannot be used due to topography issues,convewrged low area. 649 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Rmamng 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the information submitted in the application for a 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 may be suspended or revoked(.1937(g)).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 (1938(b)). Applicant/Legal Reps. Signature Required? O Yes O No Applicant/Legal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 4 / 3 0 / a 0 1 4 Authorized State Agent: Malfunction Log OYes ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 137837 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 04 / 30 / .2014 Olnch Drawing Drawing Type: Construction Authorization Scale: , OO N/Ak i J� `b 1 t4i' 0 fA1 de 1 f e ol T --VU U Page 3 of 3 P1 P2 • CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 137837 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: .0.4./ 3 0 / . 0 14 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 ITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health y P.O.Box 848/210 Hospital Street PAID �A Mocksville,NC 27028 Dau: r y (336)753-6780/Fax(336)753-1680 bg.�Ma bv?-Ob A Application For: ❑ Site Evaluation/Improvement 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 CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name D/G & �+�/,bo�5d AJ Contact Person Address 2 Home Phone 3 i/ ,$" 91 City/State/ZIP .. Business Phonej � EmailQ.Cp N 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 is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Numb 374) >�T T27� Owner's AddressAd: �/ City/Sta a/Zip,,!t&e 'S 96!E, Z7C 2.P Property Address /3'>` woeo e Cityl"A..'C.�. Lot Size Tax PIN# S 6- y Subdivision Name(if applicable)01,4 2G f/Ld b e A S Section/Lot# Z. Directions To Site: ,it' O 7"0 �0 I Ir P'� D LjC.S' ,rr I?e), 71 ivelA, e s Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW People �.. #Bedrooms _ #Bathropms �2 Garden Tub/Whitlpool es ❑No Basement: ❑Yes o Basement Plumbing: ❑Yes [?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 Water Supply Type: 2 County/City Water ❑ New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes El No 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 locatin flaggi staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Pro erty owner's or owner's legal representative signature Date(s): I -Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# 37 O U Revised 11/06 Invoice# i i , Ob aG. Pick ANDEASOA) COW5T 1,07 133 PRim Rosa RD ADVAwC E cr . 4,0 s - 4 r ^V V ?RI MRo.SI RD GJ V.J V1 : Tel)•� –���-uLtirA f1114JCtaVt1 JJ9 +7+79 (G (e7 (J• 1 APPLIGII)ON EOR SITE EYALI ATIOV/IMPROVF„11EYT PER•NIT R ATC 'Davit;Counfy Health DSpartment 'Envlrvnmental Mdalth Sec:6011 P.O. Box 4148/210 Hospital Street Hggh@Ti334, NC 27929 ' (336)751-8760 ewwIMMATA$T••* THIS APPLICATION CAJOW BE PROCESSED QW=3 ALL MM BBQIIZRBB Tmr0=&T=V IS Fa m==. Refer to the MgFOMD=ON BOW.8TI11 for iasts:uctions. - ✓1. Nene to be as11N /Gt/'��!/J'r.�od&lSt1./c(.'e.atect vsr.on Dlele iC.8dA) ✓Sr.taln9 Afdr...������ tn! c�a•e Fho,,. �/4�-75y9 , ✓cit?/at.te/za /YIA��St/IC�E A/(' :17038 ✓sYlaass pboa• C74�-7.Z7q y S. tta•e on v.cuic/ATC i!o .r.r.c thm Above xail tsq aadrus czt:y/scatelzip �-3, application For: x3ite T.vAluation O Improvament Farxdt/ASC O Both _-l. By.%—to a—Lee,XIInuse M mobile nam. 13 business Cl Industry 13 Other --i. Type eytem roquast.ad, Q Coe-.ntlonal C3 eo•..ational soditted © leowotive mss. I.f/kkoosidencet t Popple / Bedrocum —7)_ a Bathrooms y 1 ld0l,iw.6.r lSwrby.D1.paMa1 Y11es kaellae ❑iu.r•t/vlusblag �suwst/Sl.v1�rSle9 1. It auslYla/laduatry/athar: verity type t People a sinks s Cmeod.s a faon•ra s Urinals s Nater Caalers ZF FOODSffitYIC3: 11 Seats, 1[Ptimate4 MatPT ilPiga tyliiona Ptr dry) ✓-s. Type of•.star supply, 0-1 ouz.:Y/City D well O Co=w=ity s. Do You YLiclpate addstims or expansions or the raality this systtm is intended to serve?1:3 Ycs CTf o .r Ifyesrwhalt 1MPORTAiYJ`w"CLift'rl`.i MUST e0 lGt:lE THE REQUIRED PROPERTY INFORMATION REQUESTED eE E)1hvaPLATorSiT)iPL rsrrTBESUWnTED by theetteac with THIS APPLICATION. L,--Yroperty Dimensions: 6�FJX""47RtTE DIRECTtOtYS(from mocksrilk)to PROPERTY: Drax office PIN: is J7 d 3'A 'Z- 158 flvl g i'zl tProperty Addr-- Road Name two ods.tC2jEje�eI49 Citymp ro /y q 1 a f fna Subdipidac rovlde informaltin,as follows: Kame: mia leC14(,L/pn4 e R4sr= 4 Section: Block: Int:=h vffate home corners inggal: Jle2 rt� This is to certify that the laformation provided Is correct to the bat of my knowledge.I understand that any permit(s) issued hereafter are subject to suspension or revocation,If the site pians or intended use change,or if the inrornution submitted In this appliotlan is falsified or changed.1,alio, tncurrrd from this applicadom I,Ixreby,give coastal to the Authorized Representative of the Davie County Health DCpartmeat to cater upon above described propert_•located in Davie County and armed by to conduct all testing procedures as acccwry to determine the site cull ai 415-9- THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and diaseasions,str•CIUMes,sCtbadt; and scot locations). Site Revisit Ctur=e Dalc(s): Client NaUGcnttoa Date: ENS: Sign given 6 Account No. L1 Revised DCHD(WO3 Invoice 14o. • ' ' '� ' �DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION ccoun 85 Tax PIN/EH#: 5789-97-0344.02 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#02 Reference Name: Location/Address: Peoples Creek Rd.-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: —7 1^47 Water Supply: On-Site Well Community Public / Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% 20 HORIZON I DEPTH 0 -2-1 co -Z(v Texture group L Consistence , Is V Structure 51 Id- Mineralogy CT&Mineralo ss HORIZON I1 DEPTH —,51 +�, Texture group 7-5Ct—+ 24 Consistence 6'L.S0- Structure f; fl, Mineralogy 5. k HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 5 LONG-TERM ACCEPTANCE RATE d. t SITE CLASSIFICATION: EVALUATIONBY: LONG-TERM ACCEPTANCE RATE: C) 3 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-Pristpatic Mineralogy 1:1,2:1,Mixed dotes Horizon depth-In inches Depth of 611-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) jLTAR-Long-term acceptance rate-gal/da3,tft2 .A HEALTH DEPARTMENT RELEASE For office Use Only *CDP File Number 137837-2 aides Davie County Health Department 210 Hospital Street County ID Number. P.O. Box 848 HDRNVWC Evaluated For Mocksville NC 27028` Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 4 / 1 0 / a 0 a 0 UNTIL: Applicant: Anthony Sciame Property Owner: Anthony Sciame Address: 133 Primrose Road Address: 133 Primrose Road City: Advance City: Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: (336) 940-4106 Phone#: (336)940-4106 Property Location a Site Information rAddress133 Primrose Subdivision: Marchwoods Phase: Lot: 2 oad# Advance. NC 27006 SINGLE FAMILYTownship: Structure: Directions of Bedrooms: #of People: 140 to Hey 801 go south,tum left on peoplescreek,tum right Old March,tum left on march ferry the turn left on primrose 'Water Supply: PUBLIC Type of Business: Basement: E]Yes D No Total sq. Footage: No.Of Employees: 'Proposed Improvement: Garage 'R lease Conditions ` r Garage has been poured and is away from any prtion of the septic system by at least 25 feet t This release in no way expresses or implies that the existing subsurface sewage treatment and disposal ,System serving the site will continue to function for any period of time. Applicant/Legal Reps.Signature Required? OYes ONo ApplicantA-egal Reps.Signature: *Date: *Issued By: 2140-Nations,Robert *Date of Issue: 0 4 1 0 2 0 1 5 Authorized State Agent: **Site Plan/Drawing attached.** '' gHand Drawing Olmport Drawing Davie County Health Department bf ' Environmental Health Section `� P.O.Box 848 �VA� _ `i� 210 Hospital Street �. K, �� Courier# : 09-40-06 g 1 U 9� �� ��� Mocksville,NC 27028 �A Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: N y SL/'6f-w-cf Phone Number 3 3 6 (Home) Mailing Address: 3 3 10411 W/Lto,SG /' (Work) UG�/� ./t,G ZOdG Email Address: Detailed Directions To Site: 80/ A0 /-ec9i�/G Property Address: 13 3 r/m r o S e—, Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under:A!1L�-a�� Lf�i✓.S /u!moi��+1 Type Of Facility: Date System Installed(Month/Date/Year): L%GL` oZ O/`/ Number Of Bedrooms:__,� Number Of People: Z Tc'i'h'i'}+ t!'_"HY_esjor How Long? Any Known Problems? Yes No ✓If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: G G-r 6u4 ,� Number Of Bedrooms: Number of People Pool Size: Garage Size:/S X L/ Other: Requested By: Date Requested: 3�L 7 bs (Signature For Environmental Health Office Use Only Approved Disapproved Co ts: Environmental Health Special' Date: *The signing bf this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: Invoice#: