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131 Serenity Hills Trail Lot 10HEALTH DEPARTMENT RELEASE bavie County Health Department d 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 F ant: Mike Chamberlain ss: 2186 Milling Rd ty: Mocksville State2ip: NC 27028 Phone #: (336) 399-3703 For Office Use Only *CDP File Number 195656-1 County ID Number: Evaluated For: EXPANSION PERMIT VAUD 1 0/ 0 7/ 2 0 a 0 UNTIL: Property Owner. Shawn and Jill Fleming Address: 131 Serenity Hills Trail City: Advance State/Zip: NC 27006 Phone #: Property Location & Site Information Address 131 Serenity Hills Trail Subdivision: River Bend Hills Phase: Lot: 10 Road# Advance NC 27006 SINGLE FAMILY Township: 'Structure: Directions 4 of Bedrooms: 4 # of People: Hwy 158 Left on Hwy801, right on Yadkin Valley Rd. right on Griffith, left on Sandpit, left on Serenity Hills Trail "Water Supply: PUBLIC Basement: M Yes ❑ No 'Proposed Improvement: Type of Business: Total sq. Footage: No. Of Employees: Mike Chamberlain stated that the house didn't have but 3 bedroom at the time and would only pass as a 4 bedroom with this addition. 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 Authorized State Agent: *Date of Issue: 1, 0./ 0 7/ a 0 1 5 **Site Plan/Drawing attached."" e Hand Drawing 0importDrawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.Q. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 195656 -1 County File Number: Date: 1 0/ 0 7/ 2 0 1 5 Olnch Scale: OBlock Q N/A rage z of z 7V -i rage z of z 'SeV LIICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑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 13"LLETIN for instructions. APPLICANT INFORMATION Name to be Billed Anlv a rrt r• a ' t" Billing Address City/State/ZIP Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this app] (Permit is valid f r 40 months with si yp an, no a it Owner's Name / /► lig/ ! E' Owner's Address -43 I, / • . Property Addresses _ Lot Size �� ' Tax # Subdivision Name(if applicable) t ;ontact Person Home Phone 'usiness Phone ise/Facility Comers Flageed rluded: ❑ Site Plan ❑Plat(to scale) -omplete plat.) Phone Nurrber_ City/State/Zip A N 4 _City If the answer to any of the following questions is ` yiis", supporting documentation must be attached. 1 Are there any existing wastewater systems on the site? ®Yes ❑No Does the site contain jurisdictional wetlands? ❑Yes-�3No Are there any easements or right-of-ways on the site? Dyes ]BIIGTo Is the site subject to approval by another public agency? ❑Yes>No Will wastewater other than domestic sewage be generated? ❑Yes.)I�No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms a # Bathrooms S Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW AirA9e- 4Aet-& aU[ Wid/1 �dvao M Type of Facility/Business Total Square Footage of Building b People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑ Water Supply Type`,B'County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes "CNo 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 permit(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 determine compliance with applicable laws and rules. I understand that Ism responsible for the proper identification and labeling of property lines and comers and locat' d flag ' g eithe house/facility location, proposed well location and the location of any other amenities. ,. Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 ;,v Account #�� Invoice # t . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002413 Tax PIN/EH #: 5863-49-7378 Billed To: Gordon Whitney Subdivision Info: Riverbend Hills Lot # 10 Reference Name: Location/Address: Serenity Hills Trail -27006 2 ATC Number: 4443 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUEE'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 WASTEWATER CO ST/RUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �� ! Date: /�/�� �O 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 q€e� S� 140) NO. oil V-7 (5"t^' -1 c l -T4--3 fv, AP 0 -4i Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002413 Tax PIN/EH #: 5863-49-7378 Billed To: Gordon Whitney Subdivision Info: Riverbend Hills Lot # 10 Reference Name: Location/Address: Serenity Hills Trail -27006 Proposed Facility: Residence Property Size: see map TE **NOS* .um Ier: 44 0 This mprovement/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 I/ #People #Bedrooms '41#Baths<3fZ Dishwasher: rr Garbage Disposal: Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size QY-f4A4- Type Water Supply lVgrlt Design Wastewater Flow (GPD) 7 0D Site: New 0" Repair ❑ System Specifications: Tank Size/ -PP GAL. Pump T#nk//QbGAL. Trench Width CU Rock DepthJV"Linear Ft. 40 Other: Required Site Modifications/Conditions: 15A NCAC'18A.19S91! IMPROVEMENT/OPERATION PERMIT LAYOUT; APPROVED EFFLUENT FILTER RISEI (S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Depaitment 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.**** Zbd Environmental Health Specialist's Signature: DCHD 05/99 (Revised) jfci 4, �*kle Date: Juts 13 06 12:31p Gordon Whitney 336 940-6947 p.2 ` { 'S O T FOR SITE EVALUATION/IMPROVEMENT PERI,IIT & ATC Davie County Health Deparhnent j�N 1 3 2006 Envimnmenta/Hea/thSectioo P. Box 848/210 Hospital street) Moeksville, NC 27028 (336)751-8760 . a Nil "go" •* % CATION CANNOT BE PRO=SSED UNLESS ALL THE REQUIRED INFO PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Goetic a W1 +r-t'We-j Contact Berson hailing Address k ✓A M.E V "15.9 Nome Phone/tW — Win p City/Stats/zzP J404 A -o&". NG .Z?OD(r Business Phone 3A-5•- itis O 2. Siam on Permit/ATC if Different than above r' n ,S zu} s- bt ASCs Xt+ e— Hailing Address F.r_� tc 2-11p. city/stabs/zip i FLas /uG _ 2--7ca t. 3. Application For: 9 Site Evaluation ❑ Improvement Permit/ATC .-f Both t. systee to Service: J House ❑ Mobile Home 0 Business O Industry N Other S. If Residence: S People 4 9 Bedrooms 5- 4 e Bathrooms 117— Diabrasher 0 Garbage Disposal 'Q Washing Machine 11 aasemont/Plumbing If Basement/No Plumbing 6. U Business/Industry/Other: Specify. tape I People 9 sinks t: Commodes t Sbe rs • Urinals t Water Coolers IF FOODSERVICE: $ Seats Estimated Water Usage tgallons per day) 7. Type of water supply: ❑ County/City A Well II Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? C1 Yes B No If yes, what type? ••*IMPORTANT""• CLIENTS MUSTCOMPLMETHE REQUIRED PROPERTY INFORMATION REQUM-ED BELOW. Either a PLAT or SITE PLAN MUSTBE SUBMITTF_D by the client with THIS APPLICATION. Property Diatensions: WRITE DIRECTIONS (from Mnclesville) in PROPERTY: Tax Office PIN: N 15 We 417371A tjkvlrmwJ 1JAtt.E T Property Address: Road Name 4,twyrt-fs{-Tu 9.j City/Zip Aam"c.E w- z. -&o& _jece oo,L�Pr- If in a Subdivision provide inforatatioo, as follows:DIJ S E991, tm3 TQAA IS Namt: lll" 13" 4045 4AK'F aoe : � /�*t3`i/111 5_ Section: Block: Lot: _ [_{- Dal g Property Flagged: This is to certify that the inforiatadoa provided is correct to the best of Illy knowledge. 1 undcrstaad that any permit(s) Issued hereafter arc 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, andr rstand that l am responsible fur all charges incurred frau this appikedoa. I, hereby, give comvat to tkc Amthorized-Representative of the Davie County l lcaltb 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 316 ity. DATE SIGNATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Eaisting and proposed property tines and dimensions, structures,, setbacks, and septi locations). &z, , • ;3A G- S) f s Fibe-Q To Site Revisit Charge 14 f. R% VAC.. Date($). „ -- t Client Notification Date: Revised DCHD (07 ) r-1 ENS: / D ------.�Account No. t-L� Invoice No. r 7E 7� ,t. ti In F.. RAW ,3" 1. • Y 8 � s� �4 � � y y ^ R ti In F.. RAW ,3" 1. • Y R i� 4 ^ k i i TAX � u y .too r. _ �` g0 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002413 Tax PIN/EH #: 5863-49-7378 Billed To: Gordon Whitney Subdivision Info: Riverbend Hills Lot # 10 Reference Name: Location/Address: Serenity Hills Trail -27006}} ll. Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: Evaluation By: On -Site Well Y Community Auger Boring Pit Public Cute Landscape position HORIZON I •• ���r�rr�■rri■rrr�r� groupTexture Consistence • Consistence ��s�■r�r��r���ri TexturqSrouk ��r�r���►r����r�� . • ���o�■■������s� Consistence ConsistenceMineralogy HORIZON IV DEPTH Texture ����r��■�r� • CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: • REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky 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 i 1YQtcs 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) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT -0 Soil/Site Evaluation APPLICANT'S NAME ��� DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE �� G SUBDIVISION ki, C / f e Ien(l �j�: 1- Water Supply: On -Site Well ✓ Community Evaluation By: Auger Boring �� Pit t-1� ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure 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 r _ 2 Z. SITE CLASSIFICATION: EVALUATION BY: �= LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: _011em ��a C S 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky 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 Notes 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 (O1-90) ■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■iii■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■iii■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■iii■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■ilii■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ill■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■li■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ll■■■■■■l■■■■■ll■■■■111■■l■■■■■l■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ll■■■■l■■■■■■■■■ll■■l■■illi■■Illi■■ ■■■■ii■■■■■l■■■■■li■■■ ■l■ill■■i■■■■■ll■■l■■■ll■l■l■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ii■■■■ill■■■■■■■■■■■■■■■l■■■■il■■il■■■■■■■i■■■■ll■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■i■■■Ilii■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■Ill■■■■■■■■■■■■lilt■■■■■■■■■■■■■■■■■■■■■■■■■■■li■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■ ■■■■■■■■■11■■■■flim■■■■■■■■■■■■■■■■■®■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■alio■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■i.•ill■l■ii■■l■il■■■i■■■■■■m■■■■■■■■■■■■■■■■■■■■■■■ _08/14/2002 21:26 9406947 GORDON WHITNEY PAGE 02 _____ APPUCATION FOR SITE EYAIUAMWImPROVEiitm PERMIT 6 ATC Davie County Health Department ErwiAMMenls/Ne8/th SectAw P.O. Box 840/210 Hospital Street Moaksville, HC 27028 (336)751-8760 •" *IMPORTANT"** THIS APPLICATION CANNOT BE PRO=SSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Neper to the INFOWaTION BULLETIN for instructions. 1. Nae to be Gilled L-A!2Mjj iAIJIrraw% Contact Parson C Nailing Address 69 4 Qi VA-aA o ap,e Yvon. q¢o- q'4J city/state/zIp _Awhowc to. C, z-)oc>(p Business Phone 2. Nang on Permit/LSC it Different than above_ MAraaz Mailing Address city/Sate/Zip 3. Application For: 0 Site Evaluation f Improvement Permit/ATC 11 Both 6. System to Service: r House 0 Mobile Home 0 Business n Industry V Other s. If Residence: ♦ People i Bedrooms 4 / Bathrooms J(�Z 4- 4 Dishwasher LI Garbage Disposal / washing machine nasseent/Pl,mhbing II Saseaent/No Plumbing 6. If 2U#1ness/Industry/0ther: specify type t People / sinks 6 Commodes a Shovers a Urinals a water coolers IF F00DSP.Rvxcz: i Seats Estimated hater Usage (galions per dsy) 7. Type or water supply: 0 County/City 0 Rall 0 conaQurity a- Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes O No lfyes,what type? "•'IMPORTANT*•* CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED OFLOW. Either a PLAT or SITE PIAN MUSTBESUBMITTED by the client with THIS APPLICATION. Properly Dimensions. W Rr M DIRECTIONS (frons Mocksviile) to PROPERTY: Tax Office PIN: tt SSS 349 -3'7 5 Property Address: Road Name 1 b Citymp- hi)V*'UC8 �A !tj-0 P- t 1t- �11 If Ia a Subdivision provide information, as follows: , 00 L6F'r, Name wl5g No At -A -S Section: Block: Lot: it) Property Flagged: 0?i This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permit($) 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, anJers/anA/AGI /ass retponrib/r jos a//charrtt lKcsncdjran this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located is Davie County and tar by to conduct all tea Ate pr txderes as necessary to determine the site ani lity. DATE �✓ SIGNATURE THIS AREA MAY BE SED FOR DRAWING YOUR SITE PLAN (Include all of the following: Eltistin and proposed property lines and dimensions, structures, setbacks, and septic bestioas) � 5 t—• � �� �1�,� �Q�-ta p„I .Site Revisit Charge PQA O Client Notification Date: to �J R-� HA:S tI EHS: Account No. Revised DCHD (07/99) r./ U Invoke No. rm/SG to 10-kipo , • APPLICATION FOR SITE EVALUATIONAMPROVEMENT PEI FATC r fl n I7 Davie County Health Department l 11 V Environmental Health Section P. 0. Box 848 DEC 4 � , ;j Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS t , ALL Ltt THE REQUIRED INtFORMATION IS PROVIDED. 1. Name to be Billed 1'*Y\ . fi'1G +, i C'o�. {tet i �cf �.�. Contact Person 'Fz4v uo �' -►• ej S Mailing Address 3 d 1 � a t S ra; Home Phone City/State/Zip =A'.,tie. nGG , N --z 7 d0 6 Business Phone 4 Gv � c., a. 2. Name on Permit/ATC if Different than Above PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH TMs APPLICATION. Property Dimensions: d % 1 1 WRITE DIRECTIONS (from 1 Mocksville) TO PROPERTY: Tax,Office PIN: #�, f,, x Vellee r . J Property Address: Road Name RCI City/zip /`f ✓� �' �—� Y �l%D� %� 1 If in Subdivision provide information, as follows: I 1 Name: i YerBe n CL t:5- Section: sSection: Lot #: /D 1 1 1 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 lv� I- 't yo AN co "l -e-d ill, ,.. to conduct all testing procedures as necessary to determine/the site suitability. DATE' SIGNATUREC,— � A'l 4�—� Revised- DCHD (06-96) Mailing Address City/State/Zip 3. Application For: 9— Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. . System to Serve: El --House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms ❑ ,Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/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 tMell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH TMs APPLICATION. Property Dimensions: d % 1 1 WRITE DIRECTIONS (from 1 Mocksville) TO PROPERTY: Tax,Office PIN: #�, f,, x Vellee r . J Property Address: Road Name RCI City/zip /`f ✓� �' �—� Y �l%D� %� 1 If in Subdivision provide information, as follows: I 1 Name: i YerBe n CL t:5- Section: sSection: Lot #: /D 1 1 1 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 lv� I- 't yo AN co "l -e-d ill, ,.. to conduct all testing procedures as necessary to determine/the site suitability. DATE' SIGNATUREC,— � A'l 4�—� Revised- DCHD (06-96)