1344 County Home Rd Lot 1 • DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900216 Tax PIN/EH#: 5728-80-4909.01
Billed To: Paul Willard Subdivision Info: Willards Way Lot#01
Reference Name: Location/Address: County Home Road-27028
Proposed Facility: Residence Property Size: see map 1'M eounK e_
ATC Number: 3402
**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 SPIE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type1v #People #Bedrooms #Baths
Dishwasher: G?r Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type /�� #People #People/Shift 11#Seats Industrial Waste:
Lot Size �.37(D Aype Water Supply l- Design Wastewater Flow(GPD) a ' Site: New[Repair❑
System Specifications: Tank Sizea'CCOGAL. Pump Tank GAL. Trench Width Rock Depth� Linear Ft.
Other: 2 l ON OS6 . l t,�SfLL- U� to -.s qI tO.d-. Iltit rJ,
Required Site Modifications/Conditions: SY-ALL- Ota C oN-togO, It VIEEP S PEE 400SE, 101
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER( )IF 6"BELOW
FINISHED GRADE. ****NOT1 Contact a representative of the Davie County Health Department r final inspection of this
system between 8:30 a.m.to :30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#i1((336)751-8760.****
a
s
Enviro en al H ,Tpcialist's SI e: e:
T-IdMIP4
p
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mochsville,NC 27028
(336)751-8760
Account #: 989900216 Tax PIN/EH#: 5728-80-4909.01
Billed To: Paul Willard Subdivision Info: Willards Way Lot#01
Reference Name: Location/Address: County Home Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3402
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 WASTEWA N IS VALID FOR A PERIOD OF FIVE YEARS.
i n 17, li
Environmental Health Specialist's Signature: Date: 117
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 I 1 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.
�ko I E-Z-FLPLO
_
4,0rj 3%411
P2,94r
Septic System Installed By: 101 v" 1�4� I 13
Environmental Health Specialist's Signature: te:
DCHD 05/99(Revised)
C PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Health Department
i 2Q03 EnvirnnmentaiHeaith Section
MA� 4 P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
�NRaNM �WIL `TM (336)751-8760
ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed All I,, L j/�L! a Contact Person?a [,c L p r f+n deL
Mailing Address Home Phone Z,5-07
Cell
City/State/ZIP _ej DQ)PPY71 P e— 7 n� oZ'/�7�f Business Phone 2 8y• ZSIJ / � - Z ,
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: I1"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. If Residence: # People # Bedrooms 3 # Bathrooms —
VI)ishwasher ❑ Garbage Disposal FI Washing Machine . ❑ Basement/Plumbing ❑ 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: IEounty/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes RI-No
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: S EQ- Yf\Q p WRITE
DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: #_S7c �� X90!7', I / '"°L+� �O t` ��h fa-1-L /ect -
Property Address: Road Name C 11114 YYi 15:;(( i'e- C-�•ry #64f f-V-L� �� (�
City/Zip `!"n D G KS LA,1)C. rO
If in a Subdivision provide information,as follows: T G-t 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 from
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?.1' -e3 SIGNATURE 7�m GU S
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.
Revised DCHD(07/99) Invoice No.
Q rn
Lj
Uj
�T
�i
6•
} ` % '
1 ' C
N
\ CZ ` 11
ti REAR 1 X376 AC.
NCLUDE S.R. j1140 R/W
i
UOT1p1-
1, hereby certify that the Davie County Health Department
has evaluated the subdivision
entitled : WILIARD'S WAY R
with respect to criteria and conditions established t 1
by state law or promulgated thereunder and the
some is found to comply with such criteria and
conditions EXCEPT as set fouth in such evoluation. tv1-tv
For details of this evaluation and for limitations,
see the written report on file at sold department.
IMPORTANT NOTICE: THIS CERTIFICATE DOES NOT `f
CONSTITUTE A PERMIT OR APPROVAL OF INDIVIDUAL
LOT'S IN SAID SUBDIVISION FOR INSTALLATION OF
SEWAGE FACILITIES.
DATE DAME COUNTY HEALTH OFFICER
R4.3AR t �v�
N 18.24'13' A
32.$4
COUNTY HOMP RD
0
Sj� NA, .
.l ti• 1140 107.34 ch
4.4
A a 2.34 {
I, Grady L. Tutterow, certify that this plat was drawn
under my supervision from an actual survey made
under my supervision (deed description recorded in
Book Page , etc.) (other);that the
boundaries not surveyed ore clearly indicated as drawn
from information found in PL. Book __$_, Page 6; that
thot the ratio of precision is calculated as i:_+20.000 ;
that this plat was prepared in accordance with G.S.
47-30 as amended. Witness my original signature,
recistration number znd seal tni5 day of
r? . 2003
<
"I"
% S�a
t
$ 4 Iwf• Kt .
: .,. .. �a '• � ,., ::;t �o+`�i'bT'>. „ ','?;c.. :}.:� �;��4 iS• �\ mac. t' A•' � `2..':?Z• .:,�•.., ..,
......w.•}
Y
....
Ml.
P.........
Im
1.4 ON
... .. ..:.. a .. ... ..,., ..:•{ .,!(... .... ... •••;•. 'A. 1�..: .. .; �..9.$..�. q. :p!+>3ti'
\... .. ,: is. ;:� •t:; .\; :. .,...... 1 v..' •v}>}$T, �'} '\. \ } \
- .; .. .> ::1 �.tv:.� : /->' ..'yam•.'//t,� ; : yy�� ti:<:, rQ' £ \ '�a.
,:�: :: . ;. m '. •:. ., �:, �.:;;..,,,„�.. .` .}+ Ems. -,W', .;), ••}}T•, M1F.
�2
.i
�.;, '°i5` �. � ;1, :: �.'. .p..,; .. ., ...., ..>y,.`f' '^';'ti'• ,4x. .$:.{t:;: ,\ ••f��fyy����..,, ti
... �a ,. '� f ♦ A. .. cwt ,./ �r'•� '' :%,:
:.,� ;': ':;::.;;. :25.:5•. ''::
\
> : >
S
a:>
i.
.. :\\ ♦ h `L: ': J`A¢�`i�:y}•L � '_ A�T'' ,\ice. �� �y,} �'$
'; � > :x •: � Y#3' -r it 3•�a > ° Y ..\, r� / ,c}y,}{��.. x„,y,T f�Jxxd ? r
_ ..� wfi•w'>•, Q ?k'+�»,A�}f � �C T f } 9Ax�� ;�} fir' � t W,--{'i \
• � ..w � ` :. .: .: }�..�;f� C4 \ `'\ 'iC`4 �,,b,Pt t' : � V+.',y. {•�.y� 41,�. ��r �i � \ ��.1�'..
r
\
} {
1W
S
R ON—
O N T R O L S
PUMP SWITCHES CONTROL SWITCHES ALARM SYSTEMS CONTROL PANELS
77
/3,34 eeu4a� .
�.. . . a$4 aso ...
3?�
P.O.Box 1708 Detrolt lakes,AIN 56501-1708.1-888-DIAL-5/L 11-888-141-57511 ph:11M47-1317&:118-847-1617 a-mall:s/e@vs/erhombus.com