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165 Mollie Road Lot 10DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003057 Tax PIN/EH #: 5801-10-5600.10 Billed To: R.B.Hope Contracting Subdivision Info: Sheffield Downs Lot # 10 Reference Name: Location/Address: Sheffield Rd. -27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 4268 j 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 WASTEWATER CONSTRU TION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /1 Date: a424,5— CERTIFICATE 6?4S 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 nthe I I of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but sha IO`I�ias a guarantee that the system will function satisfactorily for any given period of time. �� \\ ►•J aztb TC) `DL ✓vim C- &VQF�- LJraTc?tZ ,f=I OP '))- Qsl, t J L I J FR.taJr Q04"— Lt ''TD Gdk"A l Dlb& l 7ArJt EAT& I —9 I Septic System Installed By: L Environmental Health Specialist's Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT I U� Environmental Health Section pd %a la�/O� P. O. Boa 848/210 Hospital Street ` G 6 MocknMe, NC 27028 F /)/ a�n 1 (336)751-8760 l Z IMPROVEMENT/OPERATION PERMIT Account M 990003057 Tax PIN/EH #:.5801-10-5600.10 Billed To: R.B.Hope Contracting Subdivision Info: Sheffield Downs Lot # 10 Reference Name: Location/Address: Sheffield Rd. -27028 Proposed Facility Residence ATC Number: 4268 Property Size: 1 acre **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 # #People #Bedrooms �,? #Baths - -�— Dishwasher: Garbage Disposal: ❑ Washing Machine:l' Basement w/Plumbing: ET� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply f/10 Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size GAL. Pump Tank &OGAL. Trench WidtlK:?4(p Rock Depth Linear 170;0 d Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 - 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.**** F I Lliy Uvl P k40 _ Environmental Health Specialist's Signature: !�/ Date: ,V, %,9S DCHD 05/99 (Revised) Its APPLICATION FOR SITE EVALUATION/I41PROVEMENT PEI Davie County Health Department m7wronmental Health Section P.O. Box 848/210 Hospital Street Mooksville, NC 27028 (336)751-8760. NOV 2 9 2005 ***XlfPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORZIATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. city/State/ZIP' Ad y441,4e- , n/L` 70170 Business Phone ' 2. Namo on Permit/ATC if Different than Above nailing Address C�ity/Stato/Zip 3. Application For: Site Evaluation Ml Improvement• Permit/ATC a S stem to Service• Err - house ❑ Mobile Home ❑ Business ❑ Industry ❑ Other ❑ Doth y S. Typo system requested: LY Conventional ❑ _conventional modified ❑ innovative r' acCepted 6. if 11caidencoi it People�� H Bedrooms _ fi BathroomZ s 6161hwashor ❑Garbage Disposal 311ashing Machine Ihasement/P1umlAng ❑llasemont/lie Plumbing 7. If Duoinesa/Industry /Other: verify type N People a Sinks 9 Commodoo 11 Showers tl urinals It wator Coolers IF FOODSERVICE: itSeats Estimated Water Usage (gallons per day). 'li. Type of water supply: 3 County/City - ❑.Well ❑ Community �J/ 9. Do you anticipate additions or expansions of Elle facility this system is intended to serve? ❑ Yes LTJ No If Yes, what type? ***IMPORTANT*** CLIENTS AMS'T COAIPLETL• TIIE RBQUIItED PROPERTI' INFORi4IA1'ION REQUESTED I)EL01V. Either a PLAT or SITE PLAN AMST BESURAfITTED by the client wvith TIIIS APPI,ICATION. Property Dimollsions'�^G/7Gr�eS WRITE DIRECTIONS (Grunt 1llocksviue) to PROPERTIT Tax Office PIN: It JSOa� ''�//.—S—�dD, �d 5 eXe�� Property Address: Road Name 5J e/t1 d ' City/7,11) If in a Subdivision provide informmationas follows: Namc: Sh¢7"Yi¢ &144e4 Amlywj Section: Bloch: Lot: w Date home corners flagged: r This is to certify that the information provided is correct to the best of my knowledge. I understand that any po•ulit(s) issued lnereaRcr arc subject to suspension or revocation, if the site plans or intended use change, or if file information submitted in Misapplication is falsified or changed. I, also, lulderstand thall am reshonsiblefor all charges incurredfinm this application. I, hereby, give consent to file Authorized Representative of file Davic County IIcalth Department to enter upon above described property located in Davic Comity and orvnedby to conduct all (esling procedures as necessary to determine file site suitability. SIGNATIJREI� e TIIIS AREA MAY BE USED TOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Sign given Revised DCIID (05/03 Client Notification Date: EIIS: Account No. ° s Invoice No. -:S/3 5 1. Name Lo be Billed ,� .-nt8 Contact Person 191aIle� . Mailing Address m,�// i,� Home Phone7"-Q�/� city/State/ZIP' Ad y441,4e- , n/L` 70170 Business Phone ' 2. Namo on Permit/ATC if Different than Above nailing Address C�ity/Stato/Zip 3. Application For: Site Evaluation Ml Improvement• Permit/ATC a S stem to Service• Err - house ❑ Mobile Home ❑ Business ❑ Industry ❑ Other ❑ Doth y S. Typo system requested: LY Conventional ❑ _conventional modified ❑ innovative r' acCepted 6. if 11caidencoi it People�� H Bedrooms _ fi BathroomZ s 6161hwashor ❑Garbage Disposal 311ashing Machine Ihasement/P1umlAng ❑llasemont/lie Plumbing 7. If Duoinesa/Industry /Other: verify type N People a Sinks 9 Commodoo 11 Showers tl urinals It wator Coolers IF FOODSERVICE: itSeats Estimated Water Usage (gallons per day). 'li. Type of water supply: 3 County/City - ❑.Well ❑ Community �J/ 9. Do you anticipate additions or expansions of Elle facility this system is intended to serve? ❑ Yes LTJ No If Yes, what type? ***IMPORTANT*** CLIENTS AMS'T COAIPLETL• TIIE RBQUIItED PROPERTI' INFORi4IA1'ION REQUESTED I)EL01V. Either a PLAT or SITE PLAN AMST BESURAfITTED by the client wvith TIIIS APPI,ICATION. Property Dimollsions'�^G/7Gr�eS WRITE DIRECTIONS (Grunt 1llocksviue) to PROPERTIT Tax Office PIN: It JSOa� ''�//.—S—�dD, �d 5 eXe�� Property Address: Road Name 5J e/t1 d ' City/7,11) If in a Subdivision provide informmationas follows: Namc: Sh¢7"Yi¢ &144e4 Amlywj Section: Bloch: Lot: w Date home corners flagged: r This is to certify that the information provided is correct to the best of my knowledge. I understand that any po•ulit(s) issued lnereaRcr arc subject to suspension or revocation, if the site plans or intended use change, or if file information submitted in Misapplication is falsified or changed. I, also, lulderstand thall am reshonsiblefor all charges incurredfinm this application. I, hereby, give consent to file Authorized Representative of file Davic County IIcalth Department to enter upon above described property located in Davic Comity and orvnedby to conduct all (esling procedures as necessary to determine file site suitability. SIGNATIJREI� e TIIIS AREA MAY BE USED TOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Sign given Revised DCIID (05/03 Client Notification Date: EIIS: Account No. ° s Invoice No. -:S/3 5 f J. BRYANI MCCLAMROCH E.B. 186 PG. 484 ZONED R —A 1,/2" SOLID IRON FOUND CONTRO_ CORNER I" J H G i- 0 9 0 n W m Cu n certify that !'-e Davie County Health Department �• N 7ted the subzlh4sion o SHEFFIELD ACRES z pct to criteria and conditions established ace or promulgated thereunder and the ound to comply with ouch criteria, and EXCEPT as set forth -in such evaluation. J of6vG;Ua,;0T. rittenu report on file atsaid department. } �I - NOTICE THIS CERTIFICATE DOES NOT E A PERMIT OR APPROVAL OF INDIVIDUAL AJD SUBDIVISION FOR INSTALLATION OF ACILMES DAVE COUNiY HE.AtUP- OFFICER`-.. (1 c L. Tutterow, certify that this plat was drawn la supervision from an actual survey made =� I supervision (deed description recorded in cON�ROL ; Paae , etc.) (other);that the 'CORNER •s not surveyed are clearly indicated as drawn i.rrnation found in PL. Book — , Page — • ratio of precision is calculated as 1: +20.000 plat was prepared in accordance with G.S. s amended. Witness my original signature, n,%„^.umber and seal this 25 day of I L_1 P.D., 05 t'l �) C ,111.f/J�urveyor I _ J. BRYANT MCCLAMROCH D.B. 185 PG. 484 ZONED R —A Z,3j Aa 6`3 N bg A9 I �N 82.4' 4, W t7 122.99 25'50 TOTAL) I I / I / irJ ROOT J. BY_ ETA TON v� T.B. 19O PG. 12 RALLETONE OF NORTH CAROLINA D.B. 392 , PG. 810 ZONED -T-2—S % Pa 3 CAP ROAD 09 (TiC) '57'24` I/ -��' �-an) U w t uavle county Health Department Eoyironmenta/Hea/ili Section QJVIRONMENTp�N��TM 0. Dox 848/210 Hospital Street AVIFCDUNI� Mocks 110 NC 27028 D � (336)751-07110 . • ***nIPORTANT*** TRIS APPLICATION CANNOT DN PROCESSED U24LESS ALL TIIE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions ..•I'. 1. Name to be Dilled .lL]�1A/1//e 6/27za Ile Contact Person . Mailing Address' _ %0 /Oct Ca[7h 7/Acer linea Phana City/3 tate/ZIP Z,(Rniv „_ i_p Jy� ���7/� Dduinass 1hona �% �S 2. Name on Permit/ATC if Different than Above SiQyeiQi - Mailing Address - City/State/Zip 3. Application For: 2`Site Evaluation -- ❑ Improvement Permit/ATC -❑ IIoL•h 4. 5patem to service: P-liouse -❑ M014le Home ❑ BusineDD, ❑ Industry ❑ OL•licr' y 5. Type system requested: E Convantional . ❑ conventional modified. - ❑ innovative - - 6. If Residence: It People U Bedrooms 1? p Bathroonet Z _ ❑Dishwasher ❑oarbago Disposal Meshing Machine ❑Dasemont/Plumbing ❑DaeouionL/Mo llumbing 7: If Dusinass/Indus Lry /Other: vcrify type - U People It'Disks I Commodes 0 showars - 0 Urinals, U Water Cooloru IF FOODSERVICE: # Seats - Estimated Water Usage (gallons par day) e' Typo of water supply: 2r County/City ❑ Well ❑ Colruuuni L•y ----- S. 'bo you anticipate additions or espansious or arc facility this system Is iutcuded to serve? ❑ Yes ❑ No irycs, what type? ***IdIPORTi1NP** CLIENTS AIUSTCOAl1'LETL• THE REQUIRED PROPERTY INhOIZI1•!A•1•ION ltl;QU1 S I I'D -I BELOW: L•'itttera PLAT orSITC PLAN brUSTDESU11bl/TTGD by the client iriilt'1'IIIS APPLICATION. ICATION 1'raperlyDimcnsiats: �1.���i /M -r-/ P/�0l11111TiDIRECTIONS (n)mm5lucl;svule)��w��P1tO//Pl//arrv: Ta10[ricc11IN:da/ / / Property Address: Road Nallle .S /1r ACF �� DLA- 1.('� //$ i i'id /✓ P/ / /rx� City/Zip lrin a Subdivision provide information, as foilolvs: Nantc Section: Block: Lot: _ Date honic cornets Ragged: This is to eertiry that Ha information provided is correct to the best ornty l(noudcdge. I understand tbat any perluit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use clt:utgc, or if the fir ornia tion submti(ted in tills application is falsified or changed. 1, also, widarstand [/rat '[1(111 1-eSVV1lsible jur fill c/ialVes• iaciirrrd Jroln ibisapplicatlon. I, hereby, give coliscut to the Authorized Representative orthc Davie Cuumly Ilcel(ll Delmilment to enter upon above described pruperty located in Davie County and owned by 11—S rn-. /Y%Lv//,,.;./ to eaitduct all testing procedures as necessary to dcterutilic the site suitability. DATi_ Z7 0 SIGNATURE -4 . �r TRIS AREA MAYBE usED TOR DRAWING YOUR SITE PLAN (Ltclud all of the fulloiviug: Lsistiug :old prupused property lines and dimensions, structures, setbacks, and septic locations):. '.i Site Revisit Charge Datc(s): Client Nolificatiou Date: BES: Account No.