1336 County Home Rd Lot 2 ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' P.O.Boa 848/210 Hospital Street
• Mocksville,NC 27028 3
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900216 Tax PIN/EH#: 5728-80-4909.02
Billed To: Paul Willard Subdivision Info: Willards Way Lot#02
Reference Name: Location/Address: County Home Road-27028
Proposed Facility: Residence Property Size: see map
Ispvee**NOKomnt/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 St: #People #Bedrooms 3 #Baths _
Dishwasher: Ml"— Garbage Disposal: ❑ Washing Machine:2r" Basement w/Plumbing: ❑ Basement/No Plumbing:❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑
Lot Size 0,7 ype Water Supply&Nty Design Wastewater Flow(GPD) 3bo Site: New 12"'Repair❑
System Specifications: Tank Size IWOGAL. Pump Tank GAL. Trench Width -"2V Rock Depth 12- Linear Ft.3�
Other: 2 b1.5T21e>L)Tl0r)' , I STALL- Ut'%- ' 910.c. "tt3-
Required Site Modifications/Conditions: Ir.1S7gt.t_. OM COr4002, ke Fa0p L1T, - h'01rj&
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 f°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.****
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Environmental.Hea p ialist'-s9ignature: e: (�J
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Moclksville,NC 27028
(336)751-8760
Account #: 989900216 Tax PIN/EH#: 5728-80-4909.02
Billed To: Paul Willard Subdivision Info: Willards Way Lot#02
Reference Name: Location/Address: County Home Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3403
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.19 0 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE NS CTIO V ID FOR A PERIOD OF FIVE S.
Environmental, Health Specialist's Signature: ate:
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.
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Septic System Installed By: f C to gd ,L Q
Environmental Health Specialist's Signature: ate: 2�
DCHD 05/99(Revised)
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APPLICATION FOR SITE EVALUATION/IMPROVEhIENT PERUIT&ATC
Davie County Health Department
5 ZQQ3 Environmental Health Section
M�� 2 P.O. Box 848/210 Hospital Street
,'A Mocksville, NC 27028
�ENj�1 NEA�TH (336)751-8760
.t "' EN�1R0N�,�c0111�1V
ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
r �7/
1. Name to be Billed `(I�r f,{ [� •Ao�l ct �(� Contact Person ]._ a t.L p r I?r,-n dcL•
Mailing Address D nX I l D S Home Phone ZS-0 7
j
City/State/ZIP CI DO)Ota t n e e- Y1 L I D141 Business Phone z S'L/- ZS'D 7 C3115"_7734,
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC oth
4. System to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
14.
5. ��If��Residence: # People # Bedrooms 3S, # Bathrooms-*,". �
•LYDishwasher O Garbage Disposal 'Ft Washing Machine Ll Basement/Plumbing 17 Basement-/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: 9-1`8ounty/City ❑ Well [.1 Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 17-No
If yes,what type?
'IMPORTANT'CLIENTS MUST COMPLETETIiE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: S e.e Yf\6. n WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # �i=gSj0 SID r7'_ d Z ! r-� -C]DD0r, S'c h 62-1-C
Property Address: Road Name(' /tn- 1/ YYi �e- e- G1-f I &0
citylzip_7-p b ej's LA'I) r0
If in a Subdivision provide information,as follows: 7 GY-c L-
Name:
Section: Block: Lot! _ Date Property Flagged:
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 frons
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE__ o? _D,> SIGNATURE ,dJ 'irr GU�LP �/t
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
Datc(s):
Client Notification Date:
EHS:
Account No. 1 70 6 JJ`
Revised DCHD(07/99) Invoice No. 3 Y4i7
49
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ONTROLS
PUMP SWITCHES CONTROL SWITCHES ALARM SYSTEMS CONTROL PANELS
P.O.Bax 1708 Detrolt Lakes,AIN 56502-1708 1-888-DIAL-SIE I1-888-342-57531 Ph.218-847-1317(z 218-847.4617 a-mall:sje@s/erhombus.com