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1060 Wagner Rd 1 �� A� r .�, ;* . , . � DaVie County Health Department �O�i 6f�` Environmental Health Section �:&, � , "� � �,r., � ' w P.O. Box 848 �, � _ � ;��`�,. 210 Hospital Street ���1� �i U �,. Couner# : 09-40-06 „ +.c: ; f. U � Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336) -753-1680 � ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: �/�� Phone Number (�� �� ! (Home) Mailing Address: � �'V r (Work) �(��..``j S J0/%l1. ��r �7Q 2� Email Address: Detailed Directions To Sit • Prope Address: � � Please ' n o o etrt�he-EXISTING Facility: Name System Installed Under: G�' Type Of Facility: � Date System Installed(Month/Date/Year): 7e � Number Of Bedrooms: �.�7 Number Of People: Is The Facility Currently Vacant? Yes No� If Yes,For How Long? Any Known Problems Yes No If Yes,Explain: � Please Fill In The ollowin Information About The NEW Facility: Type Of Facility: e Number Of Bedrooms: -�Number of People Pool Size: Garag ize: Other: Requested By: Date Requested: ��— /�'} (Signa re) • For Environmental Health Office Use Only A proved isapproved � ` � � 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: Paid By; Received By: Account#:���(7 � Invoice#: � . ,. • . . " � , .. , �� r ---� 7 f n �,Q ar ti 2 ^^'-J . �' _ '______________,_.._„ ^50 �• 3. ��ti b� 1 G78" ..�r��'....,�";� � ��� ��.... � f3_7 t "�+ .+"' . � «1�C�J "'/ , .. . ��i� �.��� �g$ � . . ' ; �--� 2`� x�-y , �� h..� -.___'_".,, V; ' O U2�200�'� _.--� �' ` y �f F<'+ r_ . . ... 290 �- � t( � � f��3 � � ����$ ���� � .w. y M 323 d`,' . � v C j� � o�;e�r�` All data is provided as Is without wamnty or guaratKee o}any kind ekher expressed or implied including but not limited to the implfed � ✓�� �i �4�' �� warranties of inerchantabflity or fitness for a particular use.All users ot Davie County's GIS website shall hold harmless the County of ��U N� ` � Davie,North Carolina,tts agents,eonsuttants,contnctors or employees from any and all claims or causes of action due to or aristng out printed:May 16, 2014 S of the use or inability to use tha GIS data provided by th(s we6ske. . . , , . � • � _ DAVIE COUNTY ENVIRONMENTAL H�ALTH �n,0 , P.O.Box 848/210 Hospital Sh�eet r A�j�� �v Mocksville,NC 27028 ��/ � UV v�� (336)751-8760 Fax#(336)751-8786 �� OPERATION PERMIT Account #: 990004328 Tax PIN/EH #: 5811-82-8860 . � � Billed To: Matt Logan Subdivision Info: �b60 � / �.� Reference Name: Location/Address: Wagner Road-27028 Proposed Facility: Residence Property Size: 324 acres �( / � .�� ATC Number: 4789 **NOTE**The issuance of this Operation Pernut 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 satisfactorily for any giv n period of time. � �G�,,,( �� ''_r �6'� .r� System Type: S.T.Manufacturer �G U Tank Date � Tank Size Q(� Pump Tank Siz_� � � �d�'i ^1��u . j - 1 --� S stem Installed B : '— �iP E.H. S ecialist: �- Date. e}- � Y Y�_� r 1f� � � � � \ �----� / � aF�� ,V �11- �V`v � � � °� ��° i_ _ 1��.!�t: � . ._� .,a �`L���.�i�,t, v � � ����� �� - � ` j � � � . -� " � (,� �� Y� � � �. pCHD 11/06 Revised) '� !r` . DAVIE COUNTY ENVIRONMENTAL HEALTH �� ,� P.O.Bo�848/210 Hos ital Street � � P ,�q,�, Mocksville,NC 27028 �t� (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004328 Tax PIN/EH #: 5811-82-8860 Billed To: Matt Logan Subdivision Info: Reference Name: O�� Location/Address: Wagner Road-27028 Proposed Facility: Residence `� Property Size: 3.24 acres ATC Number: 4789 �� Site Type: �Tew ❑Repair ❑Expansion **NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Envirorunental Health Section prior to issuance of any building perxnit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems,Section.1900 Sewage Treatinent 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 •���✓ Type of Water Supply: �ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)�Tank Size��'AL.Pump Tank GAL. `� �� ,� lI,,, • Trench Width� Max.Trench Depth � Rock Depth �Z Linear Ft. �'7V Site Modifications/Con itions/Other: ` c5� u.-� � G��� ��'r� �� r � �, �_. t� Contact the Davie County Environmental Health Section for final inspection of this system between 8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760. 1C�f . �. LJl�-�tJ, , ��� . �� �1s st�ted in 15A �!�AC 1F3,�.19��(5) � G�c�°pin.! Sy:;tem� ri,�y also b� us�r1 St -__(�` � �� '��� �- •, �-- � � L 1 �IZ•� � � �r , � ;� �' � , r � v ,�L�� � . . P . .,,t;.... � , _ � �V� �--�-,. � \ Environmental Health Speci list " Date: � �� DCHD 11/06(Revised) �P�,I�A� ' ITE EVALUATION/IMPROVEMENT PERMIT & ATC Q Davie County Environmental Health L?���(�1�2�L����Gt�- N�� 2 6 2�07 P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 � �3-2Q Z� ,�c��;^rEfV1ALHEALTH (336)751-8760/Fax(336 751-8786 Ef��l,.�::��= b'�"�1Y Ap lication For:,.(�;:�i�'e��va io Improvement Permit uthorization To Construct(ATC) ❑ Both Typ pplication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT 1NFORMATION Name to be Billed M�� , N Contact Person }��X�`�':.V �+^+�c��� �e.�� Billing Address � . O. a�x S�, ' Home Phone - �.��� �- City/State/ZIP t�0 C- :.�;1 � tv C. 27C��� Business Phone �� -L c�Z.C� 1 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut is valid for 60 months with site plan,no expiration with complete plat.) f � Owner's Name j��►�(- ��C��V�/ Phone Number �� 3b"�37�s) Owner's Address i�.�, U3c�c S�._,$` City/State/Zip ��c,kS'�'t���:��+✓�7-7C3L Property Address N'�1 C tv tZ.�' 'J2C�'• City 1'u1 d C,��-U� )1� Lot Size 3. Z� �,S Tax PIN# �� y -�'L-� � �� Subdivision Name(if applicable) Section/Lot# Directions To Site: 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 �No Does the site contain jurisdictional wetlands? ❑Yes ❑No Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? ❑Yes ❑No Will wastewater other than domestic sewage be generated? ❑Yes ❑No IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms j #Bat�hr oms c�` Garden Tub/Whirlpool es ❑No Basement: ❑Yes C�Ii�oo Basement Plumbing: OYes BNo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 systemrequested:. t�iConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: �ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �No 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 pernut(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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to deternune compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. ��%�!�� �� Site Revisit Charge Property owner's or owner' •i`� presentative signature Date(s): � �'�_ 2�—q'� Client Notification Date: Date EHS: Sign given �Yes ❑No Account# —1�Z�S Revised 11/06 , Invoice# ���1� ��1 � . 04/25/2007 10:00 3369832002 NANCY BRADY REALTY PAGE 02 Ppr 02 D7 davie eeunty envh4qlth 336 ?SI �786 p, 2 � '•`wy' • ,l- •'`` � � �, ;� /^,a � ... . t \���� ' \ �', � �V `�',"� �!'i'�1JC'A�`�'I4 I�QLL:aIT�:F.vALU��T1C)N/iMl'It�VEMF�1T PF:RMIT& A7 C ��, `'J � Dsv�e Co�mt�•�avlrnrtmcnc�i!Nealth ��O'� O ��� �� P.O.lioz 84H1210 I�osp►tai:�trget �� Mocksvlite,HC Z70:3 �o�,�r�'�o���� (3�6�'rst-�'rt►or�',�a�z36>7-�t-�1tu� FS�� OP� Applic �t For; Site�vetuetlrott�lmrrovemsnE Pccsnit �I Au�Swtiudon Tu Cw�suacc��'�C) f';�oth T otApplication: 6!'1GaW System ?Repatr co Ettlsring Syflem CExpe�stoMhl�dif�casion ot F.xisti��g Sysrom or Fa�ility ��'•%MPO�RTR,VT'••TtiiS APPLIC..'r�TIAN C�INNOTBE PROCCSSE,D t tvL68S ALL OF'C�iC itEc1UIREU � � , ]N� FORMATIUN 1S PROViDED. R�,fcr to the il1FORMA�IQN kiUCLE7:[N far inatructiovs_ ' � APP1.iC.AI�'T ItiI�ORItitA710N_ �.,...T_,... . - --- -_._._.�__.._ �..�. _...._ \eme to be Rilled ��`" �v�4 a•✓,C.cntact Pcrson_�N��i �Y i��c/ft� � Ditti�ng Addtr.ss.,�:Y;�2�cS`�r.l�.:�✓r ��. .—.._.__. ':iome Phonc - 22�'1 City/State/7II'��j.�' '�nxcL✓�.�,.._ -� '�,.,�P,�•�,8u>inesa 2'leout B�o _ "� 3 3G - Nacnc on PermiUA7"C if D{ff"erer�t than Abvve _ �Ivieilin�.�►ddress �� �:;itylState�Zrp w_� _ --=�.�=. �--- PRnPERTY INFOR.MATIOII __����� � tD�ta Hou:��Facili "drners Fla�vd r� .t o NOI'L•'� A survey plel or ttte p1iA mu��t aec aay t applicxian. lacl:�crl�t fsc Plan OPlat(to�cnlel (Pernut is vaGd Eot 6Q rnont�f with site�ftan,c►o axpiralinn with coaiplete p1at.) � Ux�ncr'R Namc f�,'l/ / i! �_����_C__ Phone Tlumber A _.� 4w�ner's,A.ddc:ss„��,11�.1�,��j�_1�--�__ � �f�itylStsle!'Lip,.��iCA ' •.► /�i:�i U 9/C Fzopetly 1#ddt'GS.�---./�.P.1�.L..�✓,��.n�✓ ,�L_ �-�IY�sL�,�.�.'tfLe.�,tY. ��O.T � �. t.u:Stz���,.��.a.�tl.,£.._.__lex�'INp,^--,��-=s�'�...Br�L D Subdivisiott Namcf�k appli�ablel �, Scctiotl/CAt#,_/y�_� � t�ireetic�s To Sitc:,,,,.,�.�.Y� �U..��„ 6 0� N �o�.��j� ' . �..�.�r!'11�'�.._. + ...._c�L.rl� tr.�T.d-..�..�,a�.�. �,,f.c�E _.__--�..—.--•—�. lf the answer to es f iht followirg yuestionb is"yFa".eup ortinE Aocntna�totio ct be attached. ' � Are tLes�t mp existiugwaste�.ytst epatea�6 enthe site7 �i1"cs poes the ritt tonleln jtuisdh:ti0na!wcclanels7 CJl'rs o Are Utae an7 easesncnis�r�i;ht-of-wapn on tSae g�te1 I,i(�.;s ]ri ll f%/'!� Is�he si;e�ubject to epprova►by eno�hor p��61ic�gency7 ❑S'•�a�� �Will�vq3cewster athes the��d�meatfc sewage be generated? qY.�s C o _�� � ., 1F�iESiD�NCE FILL OU7 rtJ T.�;AOX B$LUW ��people _ ,�,� #Bedooma �,� 1F�3�th��r �m�.T�,.,_ Gard�nTublVJhidpoc�l .. cs Ct�v� • f3a�scmonc: CYes =lNv 1taa�,:mencPlumbing�C]Yee KJo � �.�..--•---....,- — — .�.. _.. — .� Q=NO�i-RESIDENCE FU.L CiUT'1'H�B�X FlELOW l�pe of Facility/Dusintss__._ _�w _, Tata1 Squarc Foc tagc oCBuildin� ___,,,._#Yroplo 1 it Sinks �Comm.o�lc� _ n Showeta „� �f Urir.ats �stimated wnter Usage(gi+Tton��:r day)_�,.,.___ (Atuch do.:vmcnbtion of similgr.facility watet ca�suntptior�) ` FOODSrIt�'tC�(UNLY: �Se:,ts � �.�v--�..�•rr Per.96V=�� ..� .��«r.�-�� .r��.�v . J Typc t7stetn requested� qveniio�al aAcoepted i�innovavvc u�+t:cmaelve UC�thu,,,__ �VatctSu-�lyType:Ii/CO�tItylCity�'latcr � 'New 1ha11 �F<tuin�WCIt l' Communih Wcll �. .._ _._._,_.,.._ Do you anticipnte ndditions or eaptn:ion+af che feciliry cais:q�t_m»,�ce�afcd ca sacY�?�.Yc.. iL'1C'o I[yr.s,�that rype9 ,...,_ � __, . . ... —__.. --.r-�, - Tl�is is to ar��ify tbst ehe inCumulion prevtded on thib appl►wticn is truc e�>.d currecl to thr bt6�ot my knowledge. 1:inder:t.m:!thet auy ptrmit(sj ot.A?f:ia)i�sLed herec.Au ttrt oubJoct ta anapeniion os reva:ation it tho sice is dlered,tf�e{ntendcd use chanYc�,ur;f . . _ . . .. •......----u__.,.,.,;�n�.cn.A,.��ti■,.�w1 i hrr.:�,v rnnt rie[zt�f cnbv to the Authorized Rcprcurttntiw ����.��� �rr�o�ce��t15q 04/25/2007 10:00 3369832002 (understand that I•n�,res onsi6lc fo�:hC ib idcnttticnttoce anNaAlaouiuBRADY REALTY PAGE 04 � P t'cr v v , ...�_..__. T or sta ' g thc h�u�cKaeiliry locxtion ptoposed wefl iocation snd thc locet.vn of ony u�het�menities. rS , • • � � i� Site Rr.�icit Cherge � • • Pr ri�rn c�'s or uwntr' e�n�;ainc��casive si otvrc i nacec,): __ A r> �y � Clicnt Nu�ttcotiun Datcr,__ ,_„ � ` EH5• Date ��- •""' .rii�rt given ,.;Yts `�o Accoimt� ��"_,. Tuvind 11/(16 Imottt 9 ..,,,_...,,T_.,,. 04/25/2007 10:00 3369632002 NANCY BRADY REALTY PAGE 03 'T v• , . -� . . _ �i�/'U//� . �� u . � •�. � � ;` � �� ��l • � ..^�" l . gv ,_.___-_=-�_.--_._.____.. �o�s�` �-- � a� ro �SKj � � k ,� � 4 �� �� �� � ; � s � . � � �. � '�°�C �G �_ � ��� � �1 � ��� � -'� (,�`,� � �,�,��;�,`' � f�'� � WA �vcr �d ..._.__-----�--�----� dZ- r ,, �� "" a �� N I _ a 1 . ' • 'a i. •a.� � .���� a � _"�,_. . � � �"a` "`�,I u� � �„ `.�.f��w" � ��A ' - � F E � 4.. � �S °`. n'm��� �v.«.0 . �'. 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Eraluationllm�:rovzrTient Permit i l Autlio►�izf,tion To Cui�st�uct(A':'Cj ;: Both e of Appl;cation: C�1'�1e�v System ]Repair ta Existir.g Systerr; GExpa��.sion/hi�dificatian ot Existin�System�r Facilily �**!.'vlPORTATJ7'""*THIS APPLI�`P.TIC�N CANNOT BE PI�taC.GSSED L'NLBSS ALL OF T:I�ItEC1UIRED ^��� INFORItiiA'I'IQN IS PROVIDED. R�:fer to tb:e IirFOIt.Ivf�,T1QN BULLE7'Ii`t far i�tsh'uGtiot�s. AF'PLIC��T Pv'FORbiATION � ,�/ � \�me to be i3�lled �!1� o A•�/ ____�.cntaot Person!VA.0���.�r��c ' Billing Address��o S"K��,✓� D� __-- ::�ome Phone_,,,_[__.`���=s1�--1 City!'State/7II'��,/n),�,r� � .7_�o.�o _Business f'hone �/8 3 � ,�o z D _ 3 3� Narrr on PermiUAT'C if Differenc tlian A.bove Mailing Addr�ss _ _��� _ � �i::ityJStt�te,'Zip� � �_ FR.�F'�RTY INEQIL�'VIATION a *Date Hou:.�ei'�acility Goraecs �lag�ed�� � a �;10TE: A surve}�plat or site plan�nust acco any t ' applicaiion. lnetxded:t' i*e Plan ;:�Plat(to seale) (Pernut is t alid for 50 month� with site plan,n�expiratioi►with co:uplete plat.) � O•h�ncr's Name_ �i l/ /�������� C __.___�Pt►one T7umber�fa_ �_ O�x�rter'S Address._��j�/ �L1'��__ - (�i.rylSlate/'Lip_Cc%��.5���/a r..,/o 0 �/(� PropertyAddres�--.:�_�11._.L_'-��y1.�v' �� . City�.��.r£�t,r✓,:1�11!C �'70� a' i Lu:Sizc ,3, ?���c��,,�,_1ax YIN# SfT// -- ��._.,g�G D Subdivision Name(if appiivable)__��_ Sc��tion,�I.ot#� ��l _ I llirections To Site:!�A/c'c_,�..v �d _.__�_a0 / !'J��� �L��1�_ I ��_.h/�.. P v i��,/ ._�.1��`"� ---��11 y C'L�1` ]f the answer to an ef tlie tollowir.o qnostiuns is"yes";sup orting daeurneuca�io ust be attacl,ed. ' + • Arz tLere any existurg wasie�,atez sy;ten�s un lhe site? G�'r,s��� � Does thc sile contain jurisdic:r�onal wetlands? I:J�'es a Are diere any easenients or ri;;ht-of-way;�on the site? Ll��.s 7Ny u�'�' fr . is the site subjcct to npp:oval by anoiber public agency7 (Jl'��s �%1�s Will�vastewater athei than d.�mestic sewage bc ge�ierated? C)1��s Ci'f��o w i . IF TtEStDEI�CE FILL OUT Tl iB BOX$ELQW �� #People _,�.�/ #l�ecl o�ms �__ #Bathraom:;!�_ Gard�.n Tub/VJ'hirlpool ie�Yes CNc� • B�S�TI7C:T1I.�rYes ;KNa � Bas�::mentFlumbing OYes � � � IF 1lTOti'-RESJDEi�,'�E FILL CiUT'THE B(3X BELOW Type of Facility(Business� � Total Square Fac�lage of Buildin�� ._�#People �Sinks �C;om.mocJe:. tt 5howers ;�Urix�ats Estim�ted Watei•iJsage(gxllons��r day�),_____�____(Attach do�:Lyn�cntution of si:nilar facilit}+;vater coiisumptior�) FO�DSI;RVIG}i UNL�i': #?Se.�ts - Type syst��n reques!ed:,. onveucio:�al ��ccepted C�I�tnovati�; uA1:4mative Gl�ther _� �V�ter 5upplyType: f✓Cnur►tyJCily�Vater � = Nevr Wel! �E�:fsting W�;ll C Gammuni�� Well Do you anti�i�ate addikions or expan:io:Ls of'die faceliry this syst�rn is inte•�.ded to ser•.�e? i�; Y�s ' 'o If y�es,tiv)�at tyPe? `__._._--—,��_._ .. --- --- -- -- Tliis is to certify that the ir.farcnation�rov?ded on this applicatien�s mae a�y.3 cnrrect to 3tie best:,f my knoa�l.d�e. 1 understan3 that any permi�(s)�T,1TC(s)iss�:ed here�.Ct�r are subject to suspeiuion or revo�:ation if the site is a!tered,the intended u:c chung��s,ur if the informati��n submitted in this application is falsified or chang��i. I fieri:by grant right,f"e�b Y te the Authorized F�epreser.tati✓n � � � °J � � I � � ��f�✓ � �� � �� ��/ � -���,`�`� ��� �,�� �. v � ���� � p � 1'�� .� 9� ��p�A � ��� �. � � � �, � � 0�1 � �({^�(J�� Y, � ! � � � � � 1 � �'Or( �d S� � � � , ...� ��s�� � . n---�—�r1 � l � \�� � � � �\_-,' ��f �''; � �" , � � � � G �� ., .. t un��rstand that i am responsible fo; :17e pre}�er idenci�catioi.and lahelin�,of property lines and comc:rs aizd lo;,ating anc rtaggmg � �' or sta g the-hc�iisel�'acility Iocation proposed well location and th�locat�an of nny other amenities. _ � ' � �� t � ��, ���L � Site Revisit Charge „ . . Pr erry a� er's or owner' egaT re,�res tative si ature � - - D� lj L� Ck /, l�ate�s):_______ _.._._.__.- _'.. ���� Client Notifiaation Date: Date d EHS:l._ ____, Si c iv�n �Yes �Io Accoiznt f# �, S g Revised t 1!a6 Invoice# __________ - � '��, � Davie County Environmental Health . P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004328 Tax PIN/EH#: 5811-82-8860 Billed To: Matt Logan Subdivision Info: Address: 2920 Skyline Drive Location/Address: Wagner Road-27028 City: Pfafftown Property Size: 3.24 acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: „ New ❑Repair ❑Expansion Pemut Valid for: Years ❑No Expiration Residential Specifcations: #Bedrooms� #Bathrooms � #People_�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): �� Type of Water Supply:.�County/City ❑Well ❑Community Well Site Modifications/Pernut Conditions: S stem T e LTAR Inirial 'Y'�U?1�3�11 C- Re air � �� � � - Site Plan �Q. Ll•��' . �31_D� ��2t�'�. �� � N ._ = ti- � � � � � � � � � ��� J � �1. ['�;1 9{�/ 71�L_ �,�� � � ��� �� `�o' 1� � ►8c�' ,�,�D�� L_l�� _. �7fi3 Environmental Health Specialist � ate � /� i.p.l l-06