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116 Todd RdDAVIE COUNTY HEALTH DEPARTMENT 2 - Environmental Environmental Health Section �- P. O. Boz 848/210 Hospital Street _Z 3 -63 Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001043 Tax PIN/EH #: 5788-24-4685.02 Billed To: Richard Markland . Subdivision Info: Reference Name: Shea Stewart Location/Address: Todd Road -27006 Proposed Facility: Property Size: 2.14 Acres ATC Number: 3599 **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 #People q #Bedrooms 3 #Baths 2 - Dishwasher: Dishwasher: Ur Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: u Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size O.71y5Ac - Type Water SupplyDesign Wastewater Flow (GPD) 3(Co Site: New d Repair ❑ System Specifications: Tank Size b:D GAL. Pump Tank GAL. Trench WidtO(., Rock Depth I2 Linear Ft. �C'b Other: Li 171STQ16U T10,J Li J.:S '01,o -c— r, " . Required Site Modifications/Conditions: T>,3 JQ,% S oc-r— I c fit^ �i W r a� IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a represff4�aka of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1 • 0 1kl . on the day of installation. Telephone # is (336)751-8760.**** . - AP/ylcx 45' AA12om. 4 L — Fo�j U,Jac I rJ ►k)ay - T�i�ic Lam+-T�o� ,amu Environmental Health Specialists Signature: i_ Date: Z o DCHD 05/99 (Revised) DAME COUNTY HEALTH DEPARTMENT ` Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001043 Billed To: Richard Markland Reference Name: Shea Stewart Proposed Facility: ATC Number: 3599 Tax PIN/EH #: 5788-24-4685.02 Subdivision Info: Location/Address: Todd Road -27006 Property Size: 2.14 Acres 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 WASTE NS IONVAL D FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature. ate: 10 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. �L 3 Cl I Septic System Installed By: L `-%Zfv\ ACJ 1 Environmental Health Specialist's Signature: ate: DCHD 05/99 (Revised) '4 J APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Please complete the highlighted area(s) and Environmental Health Section return. P.O. Bon 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 li 1 - i 3 2000 EIdUIKul.,.l_u 11i,i. 1LAL1H ***n1PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ��ii/�r�Q �1G���/1�//7�i9N� Contact Person(//!a.� Mailing Address ��/�S �%(� /j'l��I,0/ S' Home Phone City/state/ZIP d4+/ Alfe, Aye vt'%i%/y Business/Phone'/ 'Z 1 — 2. sass on Bsraiti AiC if Different than Above 1 e - Mailing Address City/State/Zip 3. Application For: 11/Site Evaluation ❑ Impr&=ent Permit/ATC ❑ Both 4. System to Service: VHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 3 / 5. If Residence: # People # Bedrooms r Bathrooms /Washing N Dishwasher 11 Garbage Disposal Machine H Basement/Plumbing H Basement/No Plumbing 6. If Business/Industry/Other: specify type # People i Sinks # Commodes # Showers # Urinals N Water Coolers IF FOODSERVICE: # Seats r Estimated Water Usage (gallons per day) Q/ 7. Type of water supply: County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes (p%No If yes, what type? I***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED SEL Ove witio hilts APPLil:ATION. Property Dimensions: �, /�/ %�C'rr 1 �oh P WRITE DIRECTIONS (from Mocksville) to PROPERTY: 3,o /. 4- Ev a Tax Office PIN: #�88••��-HGY.(��'2-���s� a,� Nc✓y. toy �o ���' Lex,ti3�4,-. Property Address: Road Name �Q/ -72Y2 2 1T��Y / taf City/Zip Wim,( '1"q'VLe, 1116 a -2 If in a Subdivision provide information, as follows: Name: Section: Block: Lot:_ 2 .74 % Ai, -27, a.:/ a/?.lei Date Property Flagged: ,2ygZz-1 %/TL 's' 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. I, hereby, give consent to the Authorized Representative of the De County Health Department to enter upon above described property located in Davie County and owned by / h ar l �i1,7 r/✓/. a v r' to conduct all testing procedures as necessary to determine the site suitability. DATE 3 - to - l)D SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EUS: Account No. /L/9 Revised DCHD (07/99) Invoice No. `ewr."!"�+ �i .��, T � ,� � � .��1[ 'mss+""'� ' •� '^"�.J � �` O�•�/ MAN" �. 709.5 .. - � ��..iC .y y. 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Box 848/210 Hospital Street Courier #09-40-06 Mocicsviile, NC 27028 Phone #: (336)751-8760 April 4, 2000 Mr. Richard Markland 3155 N.C. Hwy. 801 S. Advance, NC 27006 Re: Site Evaluations — 3 Sites Todd Road Tax Office PIN: #5788-24-4685 Dear Client(s): As requested, a representative from this office visited the aforementioned sites on April 4, 2000. Based upon the information provided on the Applications) for Site Evaluation(s) and after evaluations were completed, sites 1, 2 and 3 were found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked on each site. If you have any questions, please feel free to contact this office. Sincerely, /WVt. 04aA. Robert B. Hall, Jr., R.S. Environmental Health Specialist 1 . Enclosure(s) n+�t !1F _"' �� . �'�^�" � , `.. � "«s& -m-�ss'€�§*�'"x"�. 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