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224 Random Road Lot 10DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900158 Tax PIN/EH #: 5747-17-0078 Billed To: Richard Hendricks Subdivision Info: Southwood Acres Lot # 10 Reference Name: 22`T Location/Address:. RekeFy-Bfi+re-27028 &ndo ,10' ATC Number: 4408 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FFIVE YEARS. Environmental Health Specialist's Signature: �� Date: Tc 11 A w- I / --'a l . 69 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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 grantee that the system will function satisfactorily for any given period of time. Pt L11 � 1 I-� C kjy\4 D r. Septic System Installed By: I— Q AK 4 0— Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: � J - a 9 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 rd (336)751-8760 1/00 /00 IMPROVEMENT/OPERATION PERMIT Account #: 989900158 Tax PIN/EH #: 5747-17-0078 Billed To: Richard Hendricks Subdivision Info: Southwood Acres Lot # 10 Reference Name: Location/Address: Hickory Drive -27028 Proposed Facility: Residence Property Size: 1.32 acres **NOAIIQ*%Isgmprovemn t/Operation Permit DOES NOT authorize the construction of 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People _� #Bedrooms V? #Baths.& Dishwasher: ;!f' Garbage Disposal: Ff Washing Machine: e Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply � Design Wastewater Flow (GPD) Site: NewE1JRepair ❑ System Specifications: Tank Size/1.60 GAL. Pump Tank GAL. Trench Width RockDepth 4� Linear Ft.C?D0 Other: As stated accepted Systems may also be use Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: DCHD 05/99 (Revised) APPLICA .9 SITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Health Department Environmental Health Section 1:0ementPermit P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Faxx (336)751-8786 n/Improvement Permit Authorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT TNFnRMATTON Name to be Billed kl, L.4d,' k S Contact Person Billing Address 9 Joill _ Home Phone City/State/ZIP �21�c 6,, ale— c, > &' Business Phone y0> /7s/ Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip NOTE: A survey'plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street AddressCity %✓✓��, fly., �/` Tax PIN#_j 2J71') 0 62 g Subdivision Name ts- Section/Lot# Lot Size /,33L C. Directions To Site: S -c Flo- / /'� /r't'e/? ,' i�•,,,.t R l Date House/Facility Corners Flagged S - /S - U 6, If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes 2 40 Does the site contain jurisdictional wetlands? ❑Yes i< Are there any easements or right-of-ways on the site? ❑Yes 2ff o Is the site subject to approval by another public agency? ❑Yes C1lo Will wastewater other than domestic sewage be generated? ❑Yes Ao IF RESIDEN E FILL OUT THE BOX BELOW # People �# Bedrooms � 3 # Bathrooms _� Garden Tub/Whirlpool es ❑No Basement: ❑Yes E610 Basement Plumbing: 90�es AO 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: C 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 2.1 TO 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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to termine gomplZce wi1th applicable laws and rules on the above described property located in Davie Coun andowned b��/�,L�r —� - Site Revisit Charge owner's or � -- /Sv6 Dat Sign given ❑Yes ❑No Revised 2/06 's legal representative signature Date(s): Client Notification Date: EHS: Account# ��t lN1iJ'✓" Invoice #