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146 Princeton Ct Lot 13 HEALTH DEPARTMENT RELEASE For Office Use Only *CDP File Number 158202- 1 �d r Davie County Health Department 210 Hospital Street County ID Number. � P.O.Box 848 HDR/WWC Evaluated For. Mocksville NC 27028 Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 9 / 1 9 / 2 0 1 9 UNTIL Applicant: John Beebe Property Owner. John Beebe Address: 146 Princeton Ct Address: 146 Princeton Ct City: Advance City: Advance StatefZip: NC 27006 State/Zip: NC 27006 Phone#: (336)408-8783 Phone#: (336)408-8783 Property Location& Site information Address 146 Princeton Court Subdivision: Princeton Ct Phase: Lot 13 Road#Advance NC 27006 SINGLE FAMILY Township: 'Structure: Directions #of Bedrooms: 3 #of People: Hwy 158 east tum right on Baltimore Rd.then left on Princeton Court, home on left 'water Supply: PUBLIC Basement: R Yes❑No Type of Business: Total sq.Footage: No.Of Employees: 'Proposed Improvement: Storage Building 3040 .Release Conditions c" RH 7! This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps.Signature Required? Oyes ONo Applicant/Legal Reps.Signature: *Date: *Issued By: 2140-Nations,Robert 'Date of Issue: 0 9 / 1 9 / 2 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** 4 Hand Drawing O Import Drawing b4/15/'Lb14 11;1 d�b l5 ilbtin liVtri rHut Uli 04 Davie County Health Department 4) . r Enviroamental Health Section ' PAID P.O.Box 84.8 210 Hospital Street ' � i 0 . date Courier#:094"6 Mocksville,NC 27025 Phones(836)-753.6780I.,�c($3G?-753-IM ON-Si[=WASTEWATER CERTIFICA'ITON (Check One) Replacement Remodeling Reconnection Nama ��p At•t) PhoncNumber '! 36 "tV-Zi4'" Mailing Address: <2". (Work) Email Address: Dettaaaiiled Directions To Sitc:, /&.-,is /moi- er 12 a,J 6A-cr. Property Address 2 C f-- o CT Q i//j-1-111--L4 A/C - Please Fill in I'hc Following Information About The A)US"T27V6 Facility: Name Sy-,,tem Installed Under: Type Of Facility: Date System Installed(Month/Date/Year): Number Of Bedrooms-3-NumW Of People:_,_ Is The Facility Currently Vticant? Yes (0 If Yes,For How Long? Any Known Problems? Yes Q If Yes,Explain: Please Dill In The Following Information About The N,ir WFAcility: Type Of Facility: '�Ol�Gr A4e- Jat0 eO Number Of Eedrooms: Number ofPeople Pool Size: Garage Size. Other. ,,'Requested By: Date Requested: 94L. (Si ature) For Environmental Health Office Use Only Approved Disappmved Comments: Environmental Health Specialist Date: 75le Signing of this form by the Environmental Health Staff is in no way intended,uor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Arnount:$ Date: Paid By-._ eceived By: Account#: __ 16�10ti _ _invoice#: ' ap° Nsw 1314Q? a N o�N s Lo a E� Iqb 0 � o w Z tor© ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001308 Tax PIN/EH#: 5860-81-6379 Billed To: William Joyner Builders Subdivision Info: Princeton Court section 1 Lot#13 Reference Name: Location/Address: Princeton Court-27006 Proposed Facility: Residence Property Size: 12Vx 260' ATC Number: 2696 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 ageTr ent and Disposal Systems). THIS AUTHORIZATION FOR WASTE W O N IS A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur • Date:4,:s In e ropnV3 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. Septic System Installed By: AZ Environmental Health Specialist's Signature: Date: /a 26�'a? DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section /2�T P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT iy(,, Account #: 990001308 Tax PIN/EH#: 5860-81-6379 Billed To: William Joyner Builders Subdivision Info: Princeton Court section 1 Lot#13 Reference Name: Location/Address: Princeton Court-27006 (mom Proposed Facility: Residence Property Size: 129x 260' �Z ATC Number. 2696 **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 H o oSs #People #Bedrooms j— #Baths 2•S Dishwasher: d Garbage Disposal: ❑' Washing Machine: I2"*' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supplylnn 2001-'? Design Wastewater Flow(GPDkILVO Site: New 0"' Repair❑ System Specifications: Tank Size1000GAL. Pump Tank GAL. Trench Width �Ip Rock Depth 17C Linear Ft.30O Other: Required Site Modifications/Conditions: a,LL -A4VV4 �� -�`q�G JO IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K 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.**" po.�P.�t��. • —701 10,4 • �t0' MSN. -n s' l 13 Environmental Health Specialist's Signature: Date: Z• 0/. / DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/lAIPROVEhIENT PE11A21f&Aw RR Davie County Health Department O LK Environmental Heath Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 FM - 5 20 (336)751-8760 ENViRONMENTAI HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE QU.IRE6AVit INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed f/ A/," _/��./� ��(/(�/n�,�7� Contact Person '&a py O T Mailing Address C..eele,'/�/�/�r,)�r701, /'�"�, Home Phone-1f,/,-777< ����S City/State/ZIP C l�r/imi�✓)5 / Y�C o�—��fZ Business Phone�ye- 2. Name on Permit/ATC if Different than Above Mailing Address C�ityy//State/Zip 3. Application For: ❑ Site Evaluation improvement Permit/ATC ❑ Both 4. system to Service: U ifouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms 3_ # Bathrooms Dishwasher O Garbage Disposal , washing Machine O Basement/Plumbing U Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: #1 Seats Estimated Water Usage (gallons per day) 7. Type of water supply: aunty/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes C.X6- If yes,what type? ***IMPORTANT***CLIENTS biUSTCOMPLETETHE R.EQUIRBD PROPERTY INFORMATION REQUES'T'ED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. � f Property Dimensions: 1 r t 0 WRITE DIRECTIONS(from Mocksv11/177al- Property ille)to PROPERTY: Tax Office PIN: # /� loo .421 (� / - Aq &Address: Road Name ! � �),P D Ir"ylee 1O/1 Z*Z/ City/Zip If in a Subdivision provide information,as follows: Name: Opo .rt L do rr C�t Section: _ Block: Lata l3 Date Property Flagged: _ / 3 d� 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 frvin this application. I,hereby,give consent to the Authorized Representative of the Dave County IIealth Departs to enter upon above described property located in Davie County and owned by IV/i'a tri M-7 w P'- 2Y-J'�X' � to conduct all testing procedures as necessary to determine the site suitabilit . DATE ` © � 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: EHS: Account No. v 3 Revised DCHD(07/99) Invoice.No. v�-o 7 v- 1 .0 0 a r 04 t 4 Z r �— 0 Q F Q a ,•� o E r •aa.aaow hve ! o I cop ~ � Z ' .:J s H�. } c �.. O o o - n. . zw M �• •— ,Q o v i 5 0. NG Z t` � r 4j Cd LLJ O a a m � v 1 W. E m O NN z • O 00 U CL Z o .88'611 3lot,�.5�8 S Imo+ o a a: P7 C9 M M : J ' EB cyj Viy Lu r _ " r Z:� �J Of O� _ W CoQ f..a. 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