169 Old March Rd Lot 15 rY'�.v:;,r.��wh��%`?�^fl%:�.'i^�,s"x•;•:t' �.r -.,.=.--.r_;y s»-,--*.t.�i., � �s� -�`i�w.fctir=ra. ..'iFati`'tsy s x:. :x: a�;.;{:'r�. ^z. ..ti, a` .x, -T. '
AUTHORIZATION NO: '� DAVIE OUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY;INFORMATION
Perm .O.Box 848
Name � f"""p �� � � Mocksville,'NC.27028 Subdivision Name: 1�17
7U t)� J vrJ Phone# 336-751-8760 Lot: F'
Directions Zoroperty: � Section:AUTHORIZATION FOR
►t�'d ) 6-4 �-t-t-�jt.-�5'�2�E►C �� WASTEWATER Tax OfficePlN:#
116 . 581
'-' __ SYSTEM CONSTRUCTION ,,
" QD �. t�lt.t;s^1%a M AVU1 ( 1 ?s i` ;LIU147 Road Name: 04D mA"p�p: :Z7ao(0
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building P-ermite.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G. Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
eT IS VALID FOR A PERIOD OF FIVE YEARS:
ENVIRONMLALTH SPECIAL DATEISSU�D
keg.0
6 DAVIE r OUNTY HEALTH DEPARTMENT
IMPRI EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pe ee'slC / If+ p0 1.015 r�
Subdivision Name:
Directions to property f~ t_, /%�. P t.` >J� . Section: Lot:
IMPROVEMENT J
tC.l�Lk C. L C K �?r PERMIT Tax.Office PIN:#
r,. ,tLC- ��lt 'i�'11�:'f: �'LtrC� M� .'� t ��i1�= Road Name: Ian i- 2lp dt�
**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 I l of G.S.Chapter 130A,Wastewater Systems,Section.19W Sewage Treatment and Disposal Systems)
J ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER .
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMF�N7�L HEALTH SPECIALIST DATE ISSUED
i INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE ()0—V #BEDROOMS #BATHS—Gt_#OCCUPANTS GARBAGE DISPOSALYes r'No
COMMERCIAL SPECIFICATION: FACILITY TYPE ,l #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE (cZ X10vTYPE WATER SUPPLY V rDESIGN WASTEWATER FLOW(GPD) 00 NEW SITE. V/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL PUMP TANK GAL. TRENCH WIDTH In ROCK DEPTH 1Z LINEAR FT.
OTHER 60-fl0�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
00
IMPROVEMENT PERMIT LAYOUT
OT172E L /
00P
IgD l �
rp-c4T
"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
g„ SYSTEM INSTALLED BY:
CP
�}C,s N
w� x
AUTHORIZATION NO. OPERATION PERMIT BY:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE S BEEN INSTALLED IN COMPLIANCE
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 0996(Revised)
* APPLICATION FOR SITE EVALUATIONAMPROVEM ENT PERMIT
Davie County Health Department E
L5 lh O V/
n F Environmental Health Section
do" P.O. Box 848 11J - 8 10
Mocksville NC 27028
3 6)751-8760 ENVIRONMENTALHfJlLT�4 a*.
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UAf'ESS DAVIE COUNTY "-
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed ;D,4C& 4A1J2,1-:-1Z-3O4)C.6(/S!.-ZWC . Contact Person -AUG /-f•(/t7 �D�
Mailing Address o7a S WIN6- 47 t/rN LA/.- Home Phone A 7S7 I
City/State/Zip ,MQC&S V.Ic.-,C C 2 70 a�' Business Phone 33��9q�-7x-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 ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms -3 _ # Bathrooms
I 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 PXATkW THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: R,97- Pe QA/ 6ilr CCOScO 1 WRITE DIRECTIONS(from
1 Mocksville)TO PROPERTY:
Tax Office PIN: # '7 9 7 6 . 9' C.
1
Property Address: Road Name _P1-=0P4JE-&C2rlr-A-- Opp. 1
42- 4o A
City/Zip A0yA•t r.E. Al— d-loo G
1
If in Subdivision provide information,as follows:
K
Name: M,4"e CH Won los
1 /YJ/tf�870 09oe0q
Section: Lot #:
j GU OW
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 oo to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 6 ^ 4?& SIGNATURE
Revised DCHD(06-96)
JOU MAY USE THE $ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. �f
' �� _ ____�,'J i o►� SIDNEY F. H00
D.B. 175 Pg.
/ Z "
33.47'22• E 231.61
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nj
1 110
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LOT #5
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ct
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OT,415
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LOT X17 LI�jTi,
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QST #23/ X14 D' �/ I /� ./ / 1 `�► j \ �> 1
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