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173 Valhalla Trl � �,�•r• ,.� �--4--=--� • �� Davie County Health Department �0�s f�` Environmental Health Section � .;� , �� :- .`� P.O. Box 848 � ' . C� � , ,�, 21Q Hospital Street O U �'t Courier# : 09-40-06 '• 1911 Mocksville,NC 27028 Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection -. � Name:� ���;� y' �/.�(�jjlZa (,�,l:{Cf}.� Phone Number �3(-�"°]..��-��,g� (Home) MailingAddress: /'�'� f/f}L.{�fjLC./� `�`�(({ J (-- ��(r,'�_[__��r.��'��a t'-L�� ) (Work) /r}`��C.KS!1!1�L�. ,/�� Z'70 Z.� Email Address: ��j-� 1 /�/�j / /�� -"'Detailed Directions To Site: /'i � . �(�!U '` _ �/" � �C , d/`�(� (...�l�f�� 4--1"' �s I�/�� � � -t���=�%l � �.� o �.�-�'-�. Property Address: ��� /f�j/t'f�j�j'� ' Please Fill In The Following Information`About The EXISTING Facility: � Name System Installed Under: �������Z�� � -�%'��j���+� L..-���'�� Type Of Facility:� _������'t7 .. ' . • Date System Installed(Month/Date/I'ear): ��a�`�,��t`,��� Number Of B'edrooms:�_Number Of People: � Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes ;�o If Yes,Explain: Please Fill In The F Ilowing Information About The NEW Facility: r,^^� � � � �, 'Type Of Facility: (���S _ . Number Of Bedrooms: --� Number of People Pool Size: Garage Size: Other: �:tequested By:� ,f��,�_,����,,..- ,,,�Date Requested: / ; (S�gnature) ,---"�"�- For Environmental Health Office Use Only Approve� Disapproved �C"omments: r � . Environmental Health Specialist �� ;c,t ,.(( �� t/ 1 ��. ,�,,� D'ate: �� �/� �� _- --,��---�?` *The signing of this form by the Environmental Health Staf�s 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 Chec Money Order # Amount:$ � , Date: � `,, ' Paid By: Received By: `.���(�'/i�t(..�� � � Invoice#: � ��� Account#:__ _ ��� • ��`� yr,.;i.� �+;.<- r%-y t : � Pernutcee's � � DAVIE COUNTY'-HEALTH DEPARTMENT � 7^ � � � TJame� ~ �- ���y"` ���i:`,°:� �� Environmental Health Section PROPERTY INFORMATION ` '"•} s P.O. Box 848 Directions to property:��` ��""� ij <Y:�'� � ��'� .!�;�� �1ocksville,NC 27028 Subdivision Name: � Phone#• � �f�� �,.f t j�,�1,� 1 ;,/,_ ��z„fs'�,�,r.��,/,�t . 336-751-8760 Section: Lor. i ' �' ,--- .-� ' AUTHORIZATION FOR �' ��Ji :/�I°,�r ,'�*` �%��; ,f��i�r';!.%.�T'' !I'ti'i,L--.��►f�T�'`� �f '�'tl'STEWATER Tax Office PIN:# - - � - SYSTEM CONSTRUCTION �� � AUTHORIZATION NO: +�-��� � A Road Name: Zip: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to is�uance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. � (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) .-,, .r ; , '„r'� ; ,ln,,,,, ,� � !, �r 1 ,. ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION ENVIRONM�NTAL EALTH �P$�� ALIST DATEiSS��� � � IS VALID FOR A PERIOD OF FIVE YEARS. ��� , ,-..�,'� i'y �!' � ' � � r X ��:� ;��� � ED ' RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS�#BATHS e.�#OCCUPANTS � GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY �/ / DESIGN WASTEWATER FLOW(GPD) ��� NEW SITE REPAIR SITE � r� � � SYSTEM SPECIFICATIONS: TANK SIZ��t> GAL. PUMP TANK GAL. TRENCH WIDTH �t� ROCK DEPTH /� LINEAR FT.���� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ` ' _ - IMPROVEMENT PERMIT LAYOUT �"'""�-.��.,,,,,� x;,,�„� � �� / ( � r � � � 1„1��l� , /���,11 J�{ ^ �" `� ' ,- f � . ������:� 7��'� � ` �, , - � ,- " *"CONTACT A REPRESENTATIVE OF THE DAV OUNTY TH DEPAR R FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:3 P.M. H [NSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT � � � SYSTEM INSTALLED BY: �Q A�� � P✓ � � 1 }�� . . . ��� � ... �,, �'. ` / .� . > ` . � ����� ��� . . L . , � ' � �J._ //'/ � � � . � ` � �-z�r:S'r�t�- ht�f / e, AUTHORIZATION NO V �� OPERATION PERMIT BY: �(� DATE: �` *�`THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 0?102(Revised) ����,. _ _�� �j -1 ( � ���e:-e� y 1��r �ri J �- ���Z o w�e� � �� [� � �� Q�,,���� �,� . . , � � � � " � � f ICATION FOR SITE EVALUATION IhiPftOVEhiL"NT PERh11T&ATC � J _ / : Davie County Health Department C�-,p�-e�� ��N 1 5 200� Environmenta/Hea/fh Section � ,�—�^ P.O. Box 848/210 Hospital Street � Z/`— " Mocksville, NC 27028 p'�MRONMENfALHFAL.7H (336)751-8760 COUNIY ORTANT*** THIS APPLICATION CANNOT BE PROCESS�D UNLESS ALL THE R�QUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN �or instructions. l. Name to be Billed __�..�/2�v/ �.�(,(��' Contact Person ����'7 ���}}��jQ,S'�/�Q� Mailing Address J�3 t�f�-C..f�AL�r? �'� . jL Home Phone 3�7,��-���X _ City/State/ZIP MO���f LL.� , N�+ Z�IOZS� Business Phone ��/�,-ZB�-Z�(��l/�l��Q�K1 2. Name on Permit/ATC if Differant than Above Mailing Address City/State/Zip 3. Application For: ❑ Si�e Eva�uation �provement Permit/ATC ❑ Both 4. system to service: ❑ House �1 Mobile FIome ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People 'Z. # Bedrooms �_ # Bathrooms z. ❑Dishwasher ❑Garbage Disposal �Washing Machine ❑Basement/Pliunbing ❑Basement/No Plumbing 7. If IIusiness/Indu3try /Other: verify type # People # Sinks R Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) s. Type ot water supply: ❑ County/City kSj Well ❑ Community 9. Do you anticipate additions or cxpai�sioiis of tl�c facility tliis systcm is intecidcd to servc?�1'CS ❑ lVo Ifpcs,wLat tyPc? ��flQ� T8 �jU ( C� (� (�,L1S� S(SYYI� ��-`� ***IiL1P0 �NTSMUSTC0�IPLCTLTHE REQUIREDPROPERI'YINrORl1'fATIONRCQU►3S'fEll � [3ELO�V. �ithcr a PLAT o (TG PLAN MUST 6LSUBrLfIT?'ED by thc clicnt ���ith TIIIS APPLICATION. I'roperty Dimensions: Z�D X 7s� 1VRITG DIRIsCT10Ns�r����»n-�o��;svilic)to I'ROPf;R7'1': �axOfGccPIN: #�,�'I3�3S-I'�.� 0 � I-�Y �� i So«T� � �l��r_couc�y ,�p Pc•opert��Address: Road Namc��Ll�i¢Ll.� � /C TUQI�I �I G`� 61, .O�F/1�(�(., �� � c;tyiz;P Nto cKS v��t.£. 'z�oz� " Tu►e n1 21 G I-1 T �nl C�4127�1-�n/� • If in a Subdivisioti pc•ovicic inforniatioti,as follotivs: �/�-L�t�Ll..� "�2R 1 L- �S ST(��C�/-�T�OL�11J � Nat„�: G(t���L i�ORD rS�OND (�"Ia�IC� f�dyrl� onl CfFT� Scctiou: Block: Lot: llatc honie corncrs 17aggcd:__�f' �/ 7'l�is is to ccrtifj'tll�t tI1C 1I1C0I'i711t101]I71'U�7[IC(I 1S CO!'CCCt f0 t�IC liCSt OFIll3'IC110�vledgc. I undcrstand tliat any permit(s) � issucd hcrcaftcr are subject to suspension or rcvocation,if thc sitc plans or intcndcd usc chauge,or if tlic iul'or�uatiou submitted in tt�is application is falsilied or cl�anged. I,nlsu,unclerstand tl:at I a»r responsiGle fa•al!cltarges incrn•red fi•onr this rrpplic�tron. I,I�ereby,give consent to the Authorized Representative of ttie Davie County IIcalUi Departcncut lo cnter upon aUo�•c described property located in Davie County and owned by ,[R-/l/L�j t_.C.fG4-S to cunduct all testinb pc•ocedures as necessary t0(IC�CI'I11lIlC tI1C SIfC SUItS�IIIf)�. DA7'L fi'' �o�/�L�D� SIGNATUI2E_ +��, � TIlIS AREA MAY B�US�D FOR DRAbVING YOUR SITE PLAN(Iuclude all of thc follotiving: �xisting and proposed property lincs and dimensions, structures, setbacks, and septic l�ations). ���'- p �3 g��l�'� Site Rcvisit Cliargc , . �i����1�CM�-�--' DSfC�S�: . � � C� ) 3 ��' ' � ^ Clicnt Noti�catiou Datc: •' � :.°� �.. _�,_ _.._ ��- EHS• " _ lJ�-�.__C,� �.� Sign�i��cn�_ Account No. �� � � �' � � 12c�•iscQ DCIID(OS/03 Invoic�No. � � P��� � � � � . , . . . .. ��ti4�d i��,9�,.„ L42:89A) . . m ^'�.. ..: : s� '�'�� � � 8630 ` �i � S,O $ � � m i (saas� . . .... � � ' � � � � � � "��,i �h�p0lo� +,��Y �I �..».._,q ^r�� - � , � i c�i���� i ,'� � ' � �; ,� �i � . � � � � � ' I� � �� ��,o.,aa,>- �-� � ; � 756� II � � � � �� � � 4i '�' 'h�' � -�� ,s 4�_m� _ �- � � ��,� � :��I i I����� (�ii� �������� i �"�"�>, � -L ,� . �I , , � „ � , �� d) � �� ;,-�- , ' y , ; ///r� � i' _-`E1fEf2f�fARf}F—--.-R8A6�- �-Sf2--i�83-,_� � � .. � �_�a; ,a . . . : ist27 ��` ,� .. ., � ` "�,' , . . . � � � . 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'•. 27�� ..: 364$ j5.34A) .. � �(Z,�_� � �� � ���� 5612 I�� � � � x � � ��. ����� � �� � `y � � . r�^� .n 5^Y. � � � � � a ��31� � � . � : � � ! {10.16A) � $, � 8368 (s.ain) � � � �335 \ , \� ���� '�, a � ,���� �a�. ' 4� �,�s, � �. � '� . . '`�ai (ia�J 's �e � „ . ��.�6 � . ' �,�y�� - �s � ° 'o � �I(5.6A)��� .,��'� , ��3032 �:�:. '� _ _