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181 Random RdAccount #: 990005969 Billed To: Brad Williams Reference Name: EXPANSION Proposed Facility: Apartment DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street . Mocksville, NC 27028 (336)753-6780 /Fax # (336)753-1680 OPERATION PERMIT Tax PIN: EH #: J516000001 Subdivision Into: Southwood Acres Lot # 3 Nock-, Location/Address: 181 Random Road -27028 Property Size: 0.67 Ac ATC Number: 5079 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has 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 satisfactorilyfor any given period of time. a -t a`` i:� i vi s I I( t— System Type.: S.T. Manufacturer 6ho 0-.( Tank Date Tank Size '00 Pump Tank Size Bedrooms: System Installed By: Installer# Date: GPS Coordinate: Environmental Health Specialist Date: 0 DCHD 11/06 (Revised) **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G& Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms_ # Bathrooms_ # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size , 0 0J Type of Water Supply: -County/City ❑ Well ❑ Community Well System Specifications: Design Wastewater Flow (GPD) yW Tank Size^ GAL. Pump Tank GAL. Trench Width(( Max. Trench Depth_31,t__ Rock Depth I Z� Linear Ft. �68� Site Modifications/Conditions/Other: Gy -ICG 25% QfdakY Contact the Davie County Environmental Health Section for final inspection of this system between ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street 17 Mocksville, NC 27028 1�lv (336)753-6780 / Fax # (336)753-1680 2or A AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUC4 .�_ 7_ 47 Account #: 990005969 Tax PINEH #: J516000001 ` Billed To: Brad Williams Subdivision Into: Southwood Acres Lot # 3 Reference Name: EXPANSIONLocationlAddress, 181 Random Road -27028 Proposed Facility: Apartment Properly. Size: 0.67 Ac ATC Number: 5079 Site Type: ❑New ❑Repair 19Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G& Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms_ # Bathrooms_ # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size , 0 0J Type of Water Supply: -County/City ❑ Well ❑ Community Well System Specifications: Design Wastewater Flow (GPD) yW Tank Size^ GAL. Pump Tank GAL. Trench Width(( Max. Trench Depth_31,t__ Rock Depth I Z� Linear Ft. �68� Site Modifications/Conditions/Other: Gy -ICG 25% QfdakY Contact the Davie County Environmental Health Section for final inspection of this system between 40 Davie County Health Dept PVI - °�.• h' ` 1836 Environmental Health S,. tion _ .. : - P.O. Box 848 OCT 2 2012 . 210 Hospital Street dr,, O 't Courier # : 09-40-06 1911 U Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWAT + ATION Fax: (336) - 753-1680 (Check One) Replacement emodeling Reconnection Name: a -r. -- [ p 1-1- rg 1TA-% Phone Number_j 3 L,� �qd • "1'`! -1 (Home) Mailing Address: 1$( -P-AmqZ- U117 (Work) ap y r 3 Email Address: f:1vo-A0 •, c Detailed Directions To Site: i_ceca`f �-c�cr�o�J7� r►.��p �� CQ►5.4m k 0"-w Property Address: v • 0 l- Please Fill In The Following Information About The EXISTING Facility: Ajwuk^' Name System Installed Under: BAN W `AS Type Of Facility: Mn wv-") Date System Installed (Month/Date/Year): // — / "�/ Z Number Of Bedrooms:_f_Number Of People: Is The Facility Currently Vacant? Yes (E)If Yes, For How Long?. Any Known Problems? Yes No If Yes, Please Fill In The Following Information About The NEW FacilityEy totd®l / - e 7 rJG��C C1� �G tX 1 S -F It Type Of Facility: r,�*,, nc"1� m r �l S� �' Number Of Bedrooms: Number of People l Pool Size: Garage Size: Other: Requested By: / )L/�! Date Requested: t C. amt . c) r a (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check )Money Order / # Amount:$ -, Date: 10M Paid By: ./n n M I �' t G"V r' I I �%�� Received By: Account #: Invoice #: CO it �gI2Z9 335 - up6rrde_ -0 0. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a Canitary Cnwanc Cvatcme Name Dated -s' fy Permit Number Location Subdivision Name �C�zL� oo� A Lot No. 3 Sec. or Block No. Lot Size House Mobile Home — Business -- Industry No. Bedrooms _.No. Baths —e— No. in Family _I Public Assembly Other Garbage Disposal YES ❑ NO gJ Specifications for System: Auto Dish Washer YES N NO ❑ 4 Auto Wash Ma^hine YES NO ❑ �t] �d "�✓� Type Water Supply _ *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permjt is subject to revocation if site plans or the intended use change. F l Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by IN 11 (1/ w4 Certificate of CompletionDate. AV -1.2= *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. ` DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage Systems .,.., ' Name Date57 75/ Permit Number N° 7795 Location .�/r^� "�.�� — _�°f <: �✓lr,�r. �i�fc / ,r° ✓ — �s j Subdivision Name 5 � oo �� ' Lot No. Sec. or Block No. 1 Lot Size Z House _4 Mobile Home — Business -- Industry No. Bedrooms —.No. Baths --V,— No. in Family Public Assembly Other Garbage Disposal YES ❑ NO Z Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma^hine YES [� NO ❑ a Type Water Supply ,--ter:- ------ *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. I Improvements permit by — Z - r *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion �" Date "The signing of this certificate shall indicate that the system described above has been installed in compliance with ~� the standards setfortI5 in the above regulation; but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION • APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME ��iS� l��S�� PHONE NUMBER' fsj ADDRESS 1341 S9_l /G"'-Y(f��^c' �C �C! SUBDIVISION NAME, LOT # DIRECTIONS TO SITE �s1l� ��h1�GlI��' DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY—A, 01 e NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY e4, U SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193