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181 Princeton Ct Lot 8 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Pv Mocksville,NC 27028 I (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003519 Tax PIN/EH#: G705OA0008 Billed To: Chris Gaide Subdivision Info: Princeton Lot#8 Reference Name: EXPANSION LocalioniAddress: 181 Princeton Court-270206 Proposed Facility: Expansion PropWily pe: ❑AeV ftpSair KExpansion AM(slihftJbThis5tii58iorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to.issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment 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:❑County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) Tank Size 1(ftAL.Pump Tank GAL. Trench Width " Max.Trench Deptl@EL Rock Depth Linear Ft.1�� Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30-9i30a.m.on the day of installation. Telephone#(336)751-8760. A C§? w o Environmental Health Specialis ate: IFXIr7�x11 DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 REPAIR OPERATION PERMIT € Account #: 990003519 Tax PIN:EH#: G705OA0008 Billed To: Chris Gaide Subdivision Info: Princeton Lot#8 Reference Name: EXPANSION LocationiAddress: 181 Princeton Court-270206 Proposed Facility: Expansion Peoperty Size: 1.15 Acres ** OTg** uance of this Operation Permit shall indicate the system described on the ATC has been installed AT in�compfianc-e wi 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. C System Type: S.T.Manufacturer Tank Date Tank Size Pump Tank Size System Installed By: E.H.Specialist: Date: GPS Coordinate: F ' f I DCHD 11/06(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003519 Tax PIN/EH#: G705OA0008 Billed To: Chris Gaide Subdivision Info: Princeton Lot#8 Reference Name: EXPANSION Location/Address: 181 Princeton Court-270206 Proposed Facility: Expansion Property Size: 1.15 Acres Date Evaluated: 12L2% Water Supply: On-Site Well Community Public Evaluation By: Auger Boring X Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slo % HORIZON I DEPTH D Texture group Consistence Structure Mineralogya HORIZON H DEPTH Texture group Consistence t Structure t Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: _ /A r ��n LONG-TERM ACCEPTANCE RATE: r OTHERA S)PRESENT: LIS 40(L 1 REMARKS: LEGEND Landscape Position R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope CC Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam - SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moht VFR-Very friable FR-Friable FI-Firm VFI-Very firm . EFI-Extremely firm NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky 4 NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic ... Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-.Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed lYfltr� Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised) ■■■s■■■■s■s■■s■■■■■■e■se■■■■■eee se■■■■■se■■ee■■a■■e■eee■■ecce■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■eee■■■■ee■■e■eee■■■e■■■■ee■■eee■■■ecce■■■■■■■■eee■■■eeee■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■s■■■■■■■■■■■■■■■■■■�i■■■■wipe■■■■■i■■■■■■■■■■■■e■■■■■■■e■■■■■■■ MENNENMENNEN �!iiiiii ' iiiiiiiiiiiiiiiiiiMEMNON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Davie County Health Department e1836�� Environmental Health Section P.O. Box 848 DEC 210 Hospital Street O 't l! 111 Courier# : 09-40-06 U r� 1911 Mocksville, NC 27028 . Pl►one:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 �77 (Check One) Replacement Remodeling Reconnection Name: &LIS Phone Number 336^9YC 41-05W (Home) Mailing Address,/cF/ allwe—c vd CT' 336— 399-- 3�l79 (Work) �j11,4 n/L --,"70-06 Email Address: -A/0,6 oCrlq A /Z- -GoNi Detailed Directions To Site://4,y l� � -1 5,,4LT/r"a1'-Z /Lj�, �,OL!!-`tcq� A-P f elf n/ SGT Property Address: P/ ^/e- �-1--,/ C77 A b✓4-/�5 /✓ti 7,7 a a6 Please Fill In The Following Information About The EXISTING Facility: 050AD00 i Name System Installed Under: �t dN 15 1 N &6 LL'G- Type Of Facility: Date System Installed(Monti/Date/Year): !q 02 Number Of Bedrooms: 3 Number Of People:_ Is The Facility Currently Vacant? Yes (NDo If Yes,For How Long? Any Known Problems? Yes (5) If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: S,/L- Number Of Bedrooms:__�(_Number of People Pool Size: 0 N - G ge Size: 20 X 7-7, Other: Requested By: _f—� r Date Requested:_ (Signature) For Environmental Health Office Use Only Approved Disapproved 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 ey Or;ler # Amount: Date: 12-1Z� Paid By: % �- Received By: Account#: 13T19 Invoice#: Permrttee's ,�" 4.� �` DAVIE COUNTY HEALTH DEPARTMENT Name', Environmental Health Section PO INF MATION P.O. Box 848 »a> Directions to property "�.k...`1 t��.�. �.h-+� i� Mocksville,NC 27028 Subdivision Name: '�" t.�#�.9��'_.,,-•t a ,.1 �,=f Phone#:336-751-8760 Ir. �:.a. t�,=J Section: Lot: . AUTHORIZATION FOR WASTEWATER Tax Office PIN:# 4, c SYSTEM CONSTRUCTION - - AUTHORIZATION NO: '42 A Road Name: ip wt -f t **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authbrization Number should be presented to the Davie County Building Inspections Office-when applying for Building Permits: (In compliance with Article of G.S:Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems) ***NOTICE**.*THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION I "�•, )? ` ^•. ;`- IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMM ITkL-'FtEAL fALIS - DATE SSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS 2-- #OCCUPANTS Z-1 GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE-.-Yes or No LOT SIZE I+ d TYPE WATER SUPPLY ek)k— 'Xy DESIGN WASTEWATER FLOW(GPD) 71(4-jD NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH<_' 4 ROCK DEPTH I?_ LINEAR FT. - OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: F^!:1= ` L: � CAC IMPROVEMENT PERMIT LAYOUT 44,15Q izO L1 / is �,A,5,r1 A t7 ��pM T-4,,4,r _ **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8;30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT l lI SYSTEM INSTALLED BY: r� AUTHORIZATION NO. AZOPERATION PERMIT BY: / DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I1 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 02M(Revised) �. f c _° � Permittee's ,` �' '� DAVIE COUNTY HEALTH DEPARTMENT Name:'~ iN�� r Environmental Health Section P O INF MATION r �1 :..►; �,,, *—, P.O.Box 848. --1l— Directions to property: 1--)"L'1 Iu7 Ivlocksville,NC 27028 Subdivision Name: Phone#:336-751-8760 Section: Lot: -` AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION _ - - AUTHORIZATION NO: 2 4,AtA Road Name **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the`Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. El 4EATAINEAi'fH (ALIS DATE SSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS 2— #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes/or No LOT SIZE #:. .TYPE WATER SUPPLYT�DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH _ ROCK DEPTH iZ LINEAR FT. GC7 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT > �`t��1to �_ "'� IJkaj p <74 N►� � karta� "n va� l r'r✓G cel C t+1 e N DLXS i_P-0 Jr l **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: r� v WP AUTHORIZATION NO.50Y/2,10PERATION 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 02/02(Revised) ... - .- .. 4 1, ,r Y.. _... - _ ," - -., �• __. . �. Perrrutt 's �• DAVIE COUNTY HEALTH DEPARTMENT �i c �� c ,y Name Environmental Health Section P "OPER INF�MATION U� € .. P.O. Box 848 Directions to,property: Mocksville,NC 27028 Subdivision Name: Phone#:�. 336-751-8760Y Section: Lot: ' AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - AUTHORIZATION NO. 2442 A Road Name��1ZAP: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the bavie County Building Inspections Office when applying-for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) r _ j .***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENT4CiiEktrH'SPECIALIST' DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE a. #BEDROOMS .�#BATHS ��-^ #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE 1W-i TYPE WATER SUPPLY �t''t'' f DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE a SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHROCK DEPTH 1Z LINEAR FT. OTHER l t REQUIRED SITE MODIFICATIONS/CONDITIONS: i�t:«� tf Lr�� ff I1{ ► IMPROVEMENT PERMIT LAYOUT 1t L• ' �� , L f • V. n�is /� — w 4t t � 1 { 1 i--�►;"- �h� r } a 'flc- "T i **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT r } SYSTEM INSTALLED BY: }\ Ax ✓�I t AUTHORIZATION NO. OPERATION PERMIT BY: DATE: r 1 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY M DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATME AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY IVEN PERIOD OF TIME. DCHD 02/02(Revised) 47 J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section .' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001261 Tax PIN/EH#: 5860-81-3295.08 Billed To: Stone Hinge LLC Subdivision Info: Princeton Lot#8 Reference Name: Location/Address: Baltimore Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 2897 **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 0U-1— #People #Bedrooms 3 #Baths 2 Dishwasher: 12/ Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: 17/ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water SupplyCkX)rJTt?Design Wastewater Flow(GPD) 3(40 Site: New e Repair❑ System Specifications: Tank Size 1 XGAL. Pump Tank GAL. Trench Width Rock Depth 12-" Linear Ft. Other: ` 1 J1� 1 k�LIT 1 1:30 X, . 11\'T&LL- wt,�Es ox— Required x .Required Site Modifications/Conditions: W�'Sn'\LL- Oc� l.-,DC-,yV0L%Z �ieP O G IF L I SSG IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS) IF 6 11 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.**** a,,J ©\)T a 2 #�T c1EG'to� PL�,�,P - cL1 .0 p¢QD St T% t�1 or- 4t,J5Z , 2 - 12 D Li 'S� �'10 • Environmental Health Specialist's Signature: - DCHD 05/99(Revised) r ,' ••' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001261 Tax PIN/EH#: 5860-81-3295.08 Billed To: Stone Hinge LLC Subdivision Info: Princeton Lot#8 Reference Name: Location/Address: Baltimore Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 2897 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 WASTE O N IS I OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa re: - Date: ,�N2 ©1 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. Out iv--5 la � w-� 444C ei Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) • n MEM AT ION FOR SITE EVALUATION/IMPROVEMENT PER&IIT&ATC D ►J �!1 Davie County Health Department E17 Wromei7tal Heath.Section P.O. Box 848/210 Hospital Street JUN 15 2001 Mocksville, NC 27028 (336)751-8760 ENVIRQNMENTAL-HEALTH ** PLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1 c •� 1/ 1. Name to be Billed S�n� �r-Ge L LC Contact Person 1 dy VO g( Mailing Address 0 7 n � je-sy ,,•�Od. Home Phone 7SI City/State/ZIP �MnCkj I N�� A.)C '�7Q� Business Phone go 5^ 2. Name on Permit/ATC if Different than Above Mailing Address Cit �y/State/zip 3. Application For: E Site Evaluation ,,0'Improvement Permit/ATC H Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry 11 Other 5. If Residence: / # People # Bedrooms # Bathrooms K Dishwasher LI Garbage Disposal .{d'Washing Machine WBasement/Plumbing II 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: County/City ❑ Well C1 Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes MV-0-- 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: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # S160 ' ��S' ' /tlo eL{' V/�le n 1 Property Address: Road Name k4 C2e-) S"f q(M O e-t )Zile City/Zip -1 �^ i yr�, if in a Subdivision provide information,as follows: cn.�r`� Name: ��`l r� e '-� 4 n C 0 T 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,tnnlerstand that I am responsible for all charges imcurred from this application. 1, 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 suitab' DATE CSC, �� O 1 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(In de is following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge -� Datc(s): 1� Client Notification Date: EHS: Account No. Revised DCHD(07/99) Invoice No. 9 0 Cl-1-