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796 Markland Rd Lot 9 G t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990004058 Tax PIN/EH#: 5779-85-8876 Billed To: Mary Jo Cusack Subdivision Info: Stonemoor Lot#9 Reference Name: Location/Address: Markland Road-27006 Pro osed Facility: Residence Pro a Size: ATC Number: 4469 accepted SystemsNmay also.be used 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'�orm/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 WASTE O N S VA OR A PERIOD OF FI ARS. Environmental Health Specialist's Signa e: Date: 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 guarantee that the system will function satisfactorily for any given period of time. ' -4FW47 - O v)04- Ll STS Skeptic System Installed By: Environmental Health Specialist's Signature: ate: _"7 DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT 2- .- Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 a u O (336)751-8760 I Iv IMPROVEMENT/OPERATION PERMIT Account M 990004058 Tax PIN/EH M 5779-85-8876 Billed To: Mary Jo Cusack Subdivision Info: Stonemoor Lot#9 Reference Name: Location/Address: Markland Road-27006 Proposed Facility: Residence Property Size: ATC Number: 4469 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction 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 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 � j� #People I #Bedrooms q #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #SeatsIndustrial Waste: ❑ Lot Size -3.4�t- S Type Water Supply Design Wastewater Flow(GPD) L-11460 Site: New "07Repair❑ System Specifications: Tank Size XIOWGAL. Pump TankIOLqD GAL. Trench Width 24; Rock Depth 12 Linear Ft. 4C6 Other: � 1�1�T � :E � accepted SystemsNr ay also be used Required Site Modifications/Conditions: FNS Al�-U.".! C_c9+�`+�� mom IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVE T FILTER RISERS)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representat a of the Davie Coun y Health Departmt for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p. .on theday of installation. elephonr#is(336)751-8760.**** w NJ / PMP �z�� es' CR Q: t*tAAX 'T-aJC A CID cc bc A 7- Environmental Health Specialist's Signature: hr- Date: ID ID 10 Qz-V 00 m � DCHD 05/99(Revised) • ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section .F P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 ed IMPROVEMENT/OPERATION PERMIT rblo Account #: 990004058 Tax PIN/EH#: 5779-85-8876 Billed To: Mary Jo Cusack Subdivision Info: Stonemoor Lot#9 Reference Name: Location/Address: Markland Road-27006 Proposed Facility: Residence Property Size: 49 **NO is Improvemeent/Operation Permit DOES NOT authorize the construction 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 1 l 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 CON'T'RACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type Nooses 1 #People y #Bedrooms 4 #Baths 3 Dishwasher: ❑ Garbage Disposal:❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 5A Q6^14�3 Type Water Supply VQ&TITYDesign Wastewater Flow(GPD) qq)() Site: New El/ Repair❑ System Specifications: Tank Size 1000GAL. Pump Tank CCD GAL. Trench Width :to Rock Depth,2 Linear Ft.L D1) I�ISTRI,FUTiOA �X As stated in 15A NCAC be use ) Other: accepted Systems may alsolso be used Required Site Modifications/Conditions: lySWA, f]a CpJ"f�t�2. 1�tt cS'�ST�M J`^bt rR s kL� IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVE EFFLUENT FILTER RISER(S) IF 6"BELOW u FINISHED GRADE. ****NOTICE: Contact a representative ofth e 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 y ofinstall ion. Telephone#is(336)751-8760.**** (c� -TD C1< ��� -4� �� 1,3 � D APF12M. 11D I 17►"ZINJE ` t _t ---- — Agfox, %so i:5^A 40 lay v RM 0A0gP— 1 cX�k X l2 ed l . 100, Environmental Health Specialist's Signature: 05/99(Revised) tI Jul 31 OG 10•:42a 'Cusack 704-636-0212 P. 1 L r�• APPLICATI F EVALUATION/IMPROVEMENT PERMIT&ATC JUL 3 2�$� a 'e County Health Department vironmental Health Section EMIIRONMENTAL HEALTH O.Baal 8481210 Hospital Strut iVlocksviue,NC 27028 01E COUNTY 36)751.8760/Faax(336)151-8786 Application For. 0 Site Evaluation/lm-aovemeot Permit O Aufboftition To Cottsttuet(ATC) 0 Both IMPORTAN2%04 THIS APPLIMMON C4NMOT BE PR aMED tNUESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. R.few to the INFORMATION BUf1$YN foe instructions. APPLICANT INFORMATION Nettle to be-Billed A - 1 Js5�}GK- Cu ntact Petsost _ "3�Q- Billing Address'71 S<z Home Phone 7Ct.1—CF City/StatelZIP _ C a"KI01 B"neasPhone Zoo4-2Q 3- —A>'3 3-2 LLt l Name on Pt t nit/ATC if Diffemit 11-4n Above Game.. �tSQ Ck, Mailing Address _ City/smtdZip PROPERTY MORMATION C I VL tca J1l Wzke- NOTE: A survey plat or site plata ni u.t accompany this application (Permit is valid for 60 months with site plan,no expiration vith em tete plat) ` � n ��f IPA C� Skeet AddressLo-Y MQr1L�1C�—�C _..�fy� �MCE Ta:PIldif�� �`7� �Vt Subdivision Norm t+ Qa flrr`.r Sectioc✓Lot#_q Lot Size DiheetioasToSiu: Ssi tee ,tY�[�ttC Y� �1�1(. Lc]� Cl S4Ctf±5 ala= pas= `{se mp ed {V�' Dau House/Facibly Cennscts Flant d If the answer to any of the Mowing quistions is W.supporting doaumewation inapt be suscir& Are there any existing waskvritex"cans;on the site? GYes Docs the sik contain jatisdittional wtthurds? Oyes 0 Arc there any csswxm or right-o6-ways on the site? )!Ycs[]No is the site subject to gTmrd by awdxr public agenry7 Oyes$No Will wastewater other than domestic sewage be generated? OYes*10 IF RESIDENCE FILL OUT THE BOX BELOW tl People a Betlrcmros �J_ #Bathrooms Garden Tub7wbirlpool MYes Mo BascmrnL DYcs)0No Bascrucnt Plumbing: OYes RO IF NON-RESIDENCE PILL OUT THE BOX BELOW Type of FacilityBtssiness Total Square Foot<ge of Btnldinr #Poopie #Sinter #Commodes_ #Showers _ 0 Urinals Estiroded Water l7ate(galh-ins per day) (Anachdoctmentationofsitm7arftdlitywaterconsunption) FOODSERVICE ONLY: #Sats Type systunrequested: OConveational CAccepted 1_31amovadve UAlternatiw 00111er Water Supply Type-1 Counry/City Ws Lar O New Well OExiitingWeli U('ornman'tty Well Do you anticipate additions or expansic m of the facility this systerin is intend!d to serve?13 Yes (�,No If yes,what type? ` This is to certify that the information ptwvided an this application is true and P to the best of my Irnowrledgn I understand that any pcnnit(s)or ATC(s)issued bereaftt it are subject to suspension or revocation if ole site is attend,the intended use changes.or if the information submitted in this appticition is falstYud or changed I order.-:and tLat!em v emmhnahle for aft eheuger lnurrred from this apphoarfan. I beeby grant sight of entry to the Authorized Represcmtive of the Davie County Health Deperonrot to conduct necessary finpeetiohhs to determine eomphaoee with applicable laws and nuns on the,bent:described property located in Davic County and ommod by Si tr't /Y10.f11-Tt D wAce Site Revisit Charge Property owtur i o er'e legal teprt umative signature clientNotiliatitn Date. Dzic EHS-- Sign given Oyes 0N0 Account t 40 0 Revised 2106 invoice# Jul .31 06 , 10:42a Jim Cusack 704-636-0212 ra�C- u1i < s rtu., t^u, Vin, _ . -•-- _. .-._...... - -""-'-'~ v\ r' a i i http:/,/maps.co.davie.nc.us/output/davie DCGISWEB273626604029.png 7/6/2006 t DAVIE COUNTY HEALTH DEPARTMENT r.. Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 �Ovl (336)751-8760 CK IMPROVEMENT/OPERATION PERMIT Account M 990002433 Tax PIN/EH#: 5789-16-0725.09 Billed To: Jeff Jones Subdivision Info: --!4o►1ern ooY Reference Name: Location/Address: Markland Road-27028 Proposed Facility: Residence Property Size: 3.4 acres **NOT *This7mpro4ement/Operation Permit DOES NOT authorize the construction 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 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 TtboEWL #People #Bedrooms " #Baths 3 Dishwasher: [R"� Garbage Disposal: 62"' Washing Machine: r9' Basement w/Plumbing: 121� Basement/No Plumbing: ❑ Commercial Specification: Facility Type ``#People #People/Shift #Seats Industrial Waste: ❑ Lot Size 3.14 4C�WjType Water Supply �Design Wastewater Flow(GPD) Site: New Repair❑ System Specifications: Tank Size ICCOGAL. Pump Tank 1000 AL. Trench Width Rock Depth t7- Linear Ft.4D� , �\� As stated In 15A NCAC Iso be used Other: � �� l L� dlJ � accepted Systems may also be used �r�n I Required Site Modifications/Conditions: l �C���S�e.SfOJQ , I � `--b �oV`CQs.G1L IMPROVEMENT/OPERATION PERMIT LAYO - APPROVED EFFLUENT FILTER RISER(S)IF 6 11 BELOW FINISHED GRADE. ****NOTICE: Contact a rer tative 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.t m.on the day of installation. Telephone#is(336)751-8760.**** a,Pf�c..9o' t-1Gc1�l�r.S�S t►-S f�� r -rl sr 77Q.k � N MM,a.�S, Q RMv VA I Cd vironmental Health Specialist's Signature I —91–\I 2 Date: rDCHD /99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002433 Tax PIN/EH#: 5789-16-0725.09 Billed To: Jeff Jones Subdivision Info: Reference Name: Location/Address: Markland Road-27028 Proposed Facility: Residence Pro a Size: 3.4 acres As stated in 15A NCAC 18A.1969(5) ATC Number: 4297 accepted Systems may also be used 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 Treatq=t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTR V ID A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: lk"o 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 guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) E API' 1 N FOR SITE EVALUATION/lAIPROVChifM PERMIT&ATC VV 7 2005 Davie County Health Department DEG. Environmental Health section .O. Box 848/210 Hospital Street NMENTALHEI` l Mocksville, NC 27028 4 DOAVIECOM- (336)751-8760 [— ***I11IP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORI•IATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed /, Contact Pernon 011:7Mailing Address �� Home Phone ZQ 11 f� City/State/ZIP L/�C� �C_,i��LV, Business Phone 51-22 2 V2 V 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: .-LL/Site Evaluation gxmprovement Permit/ATC Both 4. System to Service: /i X•IIouue ❑ idobiiu Honte ❑ 1Buuineas ❑ InduLtry ❑ 0L•hel 5. Typo system requested: KConventional ❑ conventional modified ❑ innovative MacCepted 6. If ;Residence: U People 11 Bedrooms 4 11 Bathrooms 3 DishwasherCarbago Disposal Washing 14achino XIB asement/Plumbing ❑basement/No Plumbing 9r� 7.. If Business/Industry /Other: verify type 9 People f1 Sinks N Commodes 11 Showers t1 Urinals t1 Water Coolers IF FOODSERVICE: it Seats Estimated Water Usage (gallons par day) 8. Type of water supply: County/City ❑ Well. ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑ No If ycs,titi•hat type? ***L1IP0RTilN2-**CLILNTS.4fUST COMPLETE THE REQUIRED PROPERTY INFORI-IATION REQUESTED II1;LO1Y. Either n PLAT or SITE PLAN h1U.ST RESUIIM=ED by the client with ruIS APPLICATION. Property Dimcustoti� ITE DIRECTIONS(from 11•Iucksville)to PROPERTY:* Tax office PIN: it S7gg16 o7;25 14 w 158 �E, 9 dh &d 11 Property Address: Road Name M arkl o tiq R 0-h Madel fit/ d /eU , 4 City/Zip /rya yl fit_ NC I'�'1 t (e- d h L 6 -,t • A orf/Cf vj 9-7dd G bo fCS AV f't 7V7�1 If in a Subdivision provide informalfon,as follows: Cz Namc: Section: Bloch: Lot: Date home corners flagged: '1'liis is to certify that the inforniatiou provided is correct to file best of my knowledge. I understand that any pernzit(s) issued hereafter arc subject to suspension or revocation,if the site plans or intended use change,or if Me information submitted in taus application is falsified or changed. I,also,understand that l ant responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County IIcalUz Dcpartuzcut to enter upon above described property located in Davie County and olvned by to conduct all testing procedures as necessary to determine the site suitability. DA'Z'E l�` `�� SIGNATURE :N TIIIS AREA MAY BE USED FOR DRANVING YOUR Sin?PLAN(Id&de all07 ilie following: Lsisting and proposed property lines and dimensions, structures, setbacics, and septic locations). / \ Site Revisit Charge � 1 \ Client Notification Date: I;I3S• i 233 Sign given =-_- •p 'Account \ / Revised DCI ID(05/03 Q�� Lzvoicc No'. N W� ►E NO SCALE i i VICINITY MAP i i i i i -- - - - - - - - - - - - - - - - - - - - - - - - - -- -- - - - -- -- - -- - - - -- _ _ _ ....,�/ I 071" Jpxm Po i I I g D.B. a . AG. 166 I I ! F - - - - - - ! JOHN A MINOR D.B. 118 . PG. 790D.B. 64 . PG. 421 / LOT s 341 V Amu - 6.f+/LICBa'S _ / AM/attic/&A Iftf AM LOT 8 g CV = w IMI SMI Li I*f# r•\ / LOT 7 ARJEA ar 5,21c &A 108#JVV 1 LOT B n r• 1Rll . . AJM 6.26 ACUS i � e ; AMA=CUMt ra 1016 AOV G101tcs B. MINOR LO!' i >n� LOT 4 8.25 A attaaMer is Iia LOT $ A AMUa RA fiif D.B. 180 PG. ,096 / LOT s LOT I $ fJl BLAINS SMITH • � ,pROX1M�SE LOLA110 GH 163 a �` MEp,NQERiNG GRAN 7 342 - - -r- - - - � .. �. // I 1 I �� ( I I I � I 1 I I • . , • / 1 I I � I I i I � / I I I . e •• P / I 1 I /� I I I ( � r i I I . ALAN BAILEY I 1 I I I I I I 1 COVINGTON CRBBI ,P 1 I, GRADY L. TUTTEROW, CERTIFY THAT UNDER MY DIRECTION AND SUPERVISION, THIS MAP WAS DRAWN FROM AN ACTUAL FIELD SURVEY MADE BY TUTTEROW SURVEYING COMPANY, ?KLLtWNAR --------------------------------------- PROFESSIONAL LAND SURVEYpR L-2527 J TUTTEROW SURVEYING COMPANY 107 NORTH SALISBURY ST. MOCKSVILLE, N.C. 27028 (336) 751 -5616 J iNAW PRELIMINARY MAP, STONE'MOOR MARKLAND ROAD, ADVANCE REVISIONS SCALE, t" = 150' APFIMED i+r, IRMN By, mw, CSPRINGS SEPT. 1 2005 fcF:LE D, Mt I SU 75 U 150 300 450 FRANK AND CHARLES POTTS PROPERTY SHADY GROVE TOWNSHIP SCALE IN FEET NtAVING NUIGM TAX MAP REF.. H-8, P/0 10 w ,_ • DAVIE COUNTY HEALTH DEPARTMENT j Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002433 Tax PIN/EH#: 5789-16-0725.09 Billed To: Jeff Jones Subdivision Info: Reference Name: Location/Address: Markland Road-27028 Proposed Facility: Residence Property Size: 3.4 acres Date Evaluated: 1 i}O o Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ✓ Cut FACTORS 1 2 ic 5 6 7 Landscape position L 'L► Slo % (, ` HORIZON I DEPTH C>- 16 -i 1 - 10 Texture group S LL F..� Consistence Gza5p F'SSSP S. Structure Mineralogy S HORIZON 11 DEPTH 10 -40 11 -77 CO- Texture -Texture rou S L. . 'S Consistence S Q lvrspl; Structure k S 61L Mineralo S Zk..Q TS HORIZON III DEPTH L10 -6(p 22V 19_q91 7AI-04 Texture group SL} S c k e- Sr t S Consistence ; 5 S f�'-SC S Structure Sr3k Mineralogy S'p S� HORIZON IV DEPTH - Texture group S Consistence n! Structure Mineralogy SOIL WETNESS $cu.4r�3ti RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION- LONG-TERM ACCEPTANCE RATE ©• p- SITE CLASSIFICATION: EVALUATION B'6;�2� LONG-TERM ACCEPTANCE RATE: �' I OTHER(S)PRESENT- REMARKS: K�.l l�'. 1._v'CTU a to iff 2 0 Sc-+<,e . ALLIVIA _ S�L S LEGEND Landscape Position R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS -Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay -- CONSIST .NCR VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI=Extremely firm 3yri NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic ,Structure SC-Single grain ., M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less .Classification-S(suitable),PS(provisionally.suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised) :a 1� l ■■■■■■■■■■■■■■e■■e■■■■■■■■■■■I■■■��■■■■eye■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■rye■■■I■■■■■■■■■■■■es■■■ 11:::::: MEMNON :::::: MENNEN MENNENMENNEN CEMMONSEMMONS ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■,■■■■■■■■■■■■■■■■i!■■e■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■I/■■■■■■ ■ilii■■e■■■■■■■■I!■■■e■■■■■■■■■■■■ MEN SOMME■■■■■■■■■■/■■■■■■■■■■■■■■■■ZiQF iiiiiii:R1■■■■■■11■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■►I■■eee■■■■e■■e■�ililel■■■■■■■■■■■■II■■■■■e■■■■■■■■■■ ■■■■■■■■■■■■■■■■I■■■■■■■■■■■■■■■■■■iL'X11■■■■1!!r�■■■■11■■■■■■■■■■�■■■■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002433 Tax PIN/EH#: 5789-16-0725.09 Billed To: Jeff Jones Subdivision Info: Reference Name: Location/Address: Markland Road-27028 Proposed Facility: Residence Pro a Size: 3.4 acres As stated in 15A NCAC 18A.1969(5) ATC Number: 4297 accepted Systems may also be used 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 Treatq=t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTR V ID A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: lk"o 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 guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised)