143 Old March Rd Lot 13 4AUT Yr5RIZATiON NO; 9 7 9 DAVIE C .LINTY HEALTH DEPARTMENT
;Environmental Health Section PROPERTY INFORMATION
Permittee P O.Box 848
Name ,61a f, t� = Mocksville,NC 2702E Subdivision Name:
Phone# 336-751-8760
Directions to property ' ' .' ,. f r // Section: Lot:.`
'AUTHORIZATION FOR
WASTEWATER
Tax Office PIN•# �.►i
SYSTEM CONSTRUCTION -
Road Name
P• �'
**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 ForriVAuthoriiation Number should be presented to the Davie County Building Inspections
Office when applying for.Building its.-
(Iri compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems).
Af y ***NOTICE*.*.*THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
s' i _ Lr'> �"► �jr ''r IS VALID FOR PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SP IALIST DATE ISSUED
1979 . DAVIEOUNTY HEALTH DEPARTMENT
� T PROPERTY INFORMATION
MPRO EMENT AND OPERATION PERMITS
Name ll '� Subdivision Name:
--Directions to property:' �' / Section. Lotl
IMPROVEMENT
PERMIT Tax Office PIN;# ``
r 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 priof to the
constructionfinstallation of a system or the issuance of a building permit
(In compliance with Article I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
f ***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-- #BEDROOMS,_?--#BATHS #OCCUPANTS - GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE- #PEOPLE #PEOPLE/SHIFT #SEATS I/NDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY d DESIGN WASTEWATER FLOW(GPD)� NEW SITEy REPAIR SITE
/ , I �f ,
, y
SYSTEM SPECIFICATIONS: TANK SIZE. GAL. PUMP TANK GAL. TRENCH WIDTH T1;1 ROCK DEPTH'_ I LINEAR F r.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PE IT LAYOUT ,APPROVED EFFLUEttT FILTER* *RISER(S) IF 6*t MOW FIRISHED GRADE*
P`°( pie
nP �p f
%'�.
op
F ,
_ I=
Ao
y
"CONTACT A REPRESENTA OF DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:3 .M:OR 1:00 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT � � SYSTEM INSTALLED BY:- -DON N
I-I toss
�Q 9 � ,
AUTHORIZATION NO. 1 s�, OPERATION PERMIT BY: ATE:
**'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE YS CRIBED ABOVE HAS BEEN INSTALLED INC PLIANCE
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.
_.
'DCHD 03/96(Revised) , .,
t
= APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT ,lM,
Davie County Health Department
Environmental Health Section D
P.O. Box 848
Mocksville NC 27028 JUN — 8 10
' ( 3 6)751-87fi0
ENVIRONMENTAL HEALTH
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE ,SS DAVIE COUNTY
ALL THE/REQUIRED(INFORMATION IS PROVIDED., n
1. Name to be Billed -AC& QND/-28 00 C.dVL .Z C . Contact Person -mel,
Mailing Address o7a S W/ill G- /`4✓r'-N Z Al- Home Phone ��:�' 7S 7 71
City/State/Zip �MOCe.S ✓!C-C.,E . Al.C 2 70 a S` Business Phone 33 r!q�-7a-79
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation Improvement Permit&ATC ❑ Both
4, System to Serve: House ❑ Mobile Home ❑ Business O Industry ❑ Other
5. If Residence: # People # Bedrooms 3 # 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: 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 P.YAWRTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: R47— 004.141/ jGiV CLy.ScO I WRITE DIRECTIONS(from
Tax Office PIN: # 7 g - 6- - 68 S ,O' �yllocksville)TO PROPERTY:
/S8 7v gal - ���
Property Address: Road NameUACF�S (2� K ASD_ 1
1 Ae- 7Z0 SOV A,1VC,,6---
City/Zip Ao✓A4A:,.=-_ o '
1
If in Subdivision provide information,as follows: 1
1 K
Name: 1n,4,,X14 W06,0 1
Section: Lot #:
1 LUcxx�s ON /r.
1
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.1,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 �Df}/ll H. H CSU r--r, to conduct all testing procedures
as necessary to determine the site suitability.
DATE6 66 6V£ SIGNATURE
Revised DCHD(06-96)
JOU MAY USE THE $ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. �V'�
---- / / j;, SIDNEY F. HOOTS /
D.B. 175 Pg. 507
----- % /' N 33.47'22' E
231.61
'N 40. -- -tQT #8
-4. HOOTS \` \110Av61 \ O� -/ /' ./ _ 7=i _ 0 0
75 P 504 \. "' o�e' �. / LO 7'' '�
+-
/ / /
110
1 `11�T ,� \\ 6 ` 4i ' '
/ i , / 1 71
//y 1 14; ,�� `1 `✓ ' ' 110n' ^ \ \ �\\\ \\\ \�\ �\ \\ i i rt'�J O9
4. 93 .\ / \ \ \ \ \ r ' '
l 4q
LOT #5
' ll� /
j�ts\` / , \ r �--� �' / / '' rfi'i / // / / CD'
LO EO i i / /I(0 / i N o N r
OT415•/� �/' j\ I I r =���\/' ,/�� % %/ / i l i �/ LOT 2 ;LOTAl QI ' b
J a33
LOT j17 ,. .
(PUBLIC)\ v1
?0'X70' SIGHTl--
/ �EASELEM(TYP) , , / / i , / // _-_-- �� ✓t - -; ?-125 ———�._130-
LOT
14
it
LOTS\ #9 I I 1
XOT �l0
'e,/ ` ( ( I I I ( — LOT PI 1 n 1 i � \\ � 91
1*2_ �/ &l ,' I \ 1 11 ��\ 1 i I i i 1 I JJ \`"N l , N N; \ I nl r `t
I 1 �I I 1 \ I I r r—�
.0
t6T 23/ LOT 1
�N- / iVOT 02
i \ `�/�ySS� �'� ��, �,/ �-i-�'LOT,i�2� //�/ 1 �r r/1 /I � / �i � \ �`\\ ;\ • �� ''-__ / 130
I �►
N �,� / LZ
TS 7T` 2 �� /�, 140
b ' / i' .' / // ' /� / / 133
504
/ii/ �'/: ��� / / "NOTES ?
/i // ALL LOTS ARE SUBJECT TD DAME COUNTY
HEALTH DEPARTMENT STANDARDS.
2• ROADS ARE TO