156 Old March Rd Lot 5 r' tDAVIE OUNTY HEALTH DEPARTMENT
-..r 1.84
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pe
Name f �y' ;.�' f �3 � t..' Subdivision Name: G"/1dLi
`Directions to property: " ' }r Section: Lot:,
IMPROVEMENT
PERMIT. Tax Office PIN:
- -
Road Name: , , '`` • UCSf,�
**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/mstallation of a system or the issuance of a building permit.
(In compliance with Article 1 I 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
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE .
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE BEDROOMS. #BATHS 'J #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCI�A{L SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT q #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE✓ /1l TYPE WATER SUPPLY ` y DESIGN WASTEWATER FLOW(GPD) �3 6� NEW SITE // PAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE AM GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DE LINEAR FT.
OTHER
:. REQUIRED SITE MODIFICATIONS/CONDITIONS:
.00
• 0
IMPROVEMENT PERMIT LAYOUT
I �
J
r
**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 PERMIT 0
SYSTEM INSTALLED BY: �
jo
r ..r-'�1� 1 tt � lal
At
AUTHORIZATION NO. OPERATION PERMIT BY: a���.L✓7. DATE: �7
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT E SYS DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
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WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME:
DCHD 0996(Revised)
1 t .
r APPLICATION FOR SITE EVALUATION/INIPROVEDIEN7'PERMIT&ATC
Davie County Health Department np
Environmental Health Section O
P.O.Box 848
Mocksville NC 27028 JUN - 8 IM
( 3 6)751
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE UNLRW§QN6IENTAL HEAUH
ALL THE REQUIRED INFORMATION IS PROV ./��� n
DAVIE COUMY
1. Name to be Billed ,Ar& iVOC eB ox)nl y3r.-rNC . Contact Person Ana x- 'UOQ$ew
Mailing Address o7a S 6OI 1/6- /7k/4:-7A/ Ln/. Home Phone - -7S7 9
City/State/Zip '�IOC.�s t/le.L,6 �2 7G a'F Business Phone 3-34 qqi-7a79
2. Name on Permit/ATC if Different than Above
Mailing Address I2 CitySt--�pp�ip 6 p
3. Application For: Site Evaluation 2rImptovement Permit&ATC ❑ Both
4. System to Serve: House O Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _— # Bathrooms
ADishwasher Garbage Disposal 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: X County/City ❑ Well ❑ 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 PLATRTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: IZ,-q7WRITE DIRECTIONS(from
Tax Office PIN: #
7 / - - S 8 S � ksville)TO PROPERTY:
7-1
Property Address: Road Name ��=OPCF�3 Cir2� K O,O_ 1
ie- rD 40 R -
City/Zip AotlAAx'e_ Al C d-)oo to '
1
If in Subdivision provide information,as follows:
1 KAQ
Name: MA Q C..H C OD ros 1
Section: Lot #: '
G{J s DAY �r.
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
� /`f
and owned by sj /. Woo r-r' to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 — 6 ^ V& SIGNATURE
Revised DCHD(06-96)
YOU AIAy USE THE BACK OF THIS )`ORA( FOR DRAWING YOUR SITE PLAN.
SIDNEY F. HOOTS /
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N 33.47'22• E '231.61 ' 2 �,--- +5-�- t NQ0 g
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NOTES
I. ALL L ARE SUBJELT GACOUNTY
NEHEALTHtH oEPAxrNExr STANDARDS.
/ II
2. ROADS ARE To RE Will rn wlvn cr.un.n..e