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129 Still Waters Drive Lot 24DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boz 848/210 Hospital Street , I Mocksville, NC 27028• w (336)751-8760 Account #: 990003738 Billed To: Gary Walker Reference Name: Gary Walker Tax PIN/EH #: 5777-33-1382.24 Subdivision Info: Still Waters Phase 1 Lot # 24 Location/Address: Hwy 801 South -27006 ATC Number: 4093 s AUTHORIZATION FOR WASTEWATER SYSTEM'CbNSTRUCTION **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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD O FIVT YEARS. Environmental Health Specialist's Signature: Date: StatAd in 1 RA MnAn accepted Systems j; 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 an given period of time. 1 Thl f` -r\"" v^' Pu � V 1 1 0 Z 16° 313 5 I � 11aXs 5� cis 38 [z IA- r1T 1 1 Septic System Installed By: ►� gCAGv S -- Environmental Health Specialist's Signature . Date: DCHD 05/99 (Revised) �r�.��ti— �^�^'p TcLv.v,: SftA F -1 boo t✓k►-.¢S 1-3 = 160 ���. Ss3- rlL.o Account M 990003738 Billed To: Gary Walker Reference Name: Gary Walker Proposed Facility: residence ATC Number: 4093 Tax PIN/EH #: 5777-33-1382.24 Subdivision Info: Still Waters Phase 1 Lot # 24 Location/Address: Hwy 801 South -27006 Property Size: 190x160 Account #: i, � r Gary Walker Account #: 990003738 Billed To: Gary Walker Reference Name: Gary Walker Proposed Facility: residence DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section P. O. Boa 848/210 Hospital Street 0 Mocksville, NC 27028 (336)751-8760 ,�Q S qW4p4 �K IMPROVEMENT/OPERATION PERMIT C6 01 Tax PIN/EH #: 5777-33-1382.24 Subdivision Info: Still Waters Phase 1 Lot # 24 Location/Address: Hwy 801 South -27006 Property Size: 190x160 TE*Numer: 4093 **NO is 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: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industtrial13�Waste: Lot Size Type Water Supply G /l1% Design Wastewater Flow (GPD) � Site: Newer Repair ❑ System Specifications: Tank Size t&AL. Pump Tank GAL. Trench Width-- o -/Rock Depth/2 Linear Ft720 Other: As stated in Required Site Modifications/Conditions: accepted Systems may also be use 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.**** Environmental Health Specialist's Signature: A,15�9�lwl Date: DCHD 05/99 (Revised) Y U D w ENVIRC,'!P+11! 71 HEr 1 TH GrrIE ('(;UNTY )N FOR SITE EVALUATION/INI1111OVENI ENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IZIPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORITATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ` • C �„ �-r.1 0"- y C Contact Person CJ 00�t�- Mailing Address 1 5 V'1L a�J Cc. W\ -e- Home Phone City/State/ZIP � � rklu �-t- iI : C. 2 13 ZU Business Phone S'�, (» •- (�, (�, q- G S 1 2. Name on Permit/ATC if Different than Above Mailing Address/SC._i,tyy/�State/Zip AN, < 3. Application For. ❑ Site Evaluation liprovement Permit/ATC ❑ Both 4. System to Service: C�YHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: tJ Conventional ❑ conventional modified ❑ innovative pacCepted 6. If .Residence: 9 People # Bedrooms -3 ## Bathrooms Z ishwasher ❑Garbage Disposal - ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Lusiness/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: It �atSeats� Estimated Water Usage (gallons per day) 8. Type of water supply: 1" County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes e -No If yes, wliat type? ***L111'0RTitN7'*** CLIENTS MUST C081PLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN h1UST BE SUBMITTED by the client with THIS APPLICATION. 1 Property Dimensions: � G o X N bb Tax Office PIN: # Property Address: Road Name+t �' w Cs''�'S City/Zip If in a Subdivision provide information, as follows: Name: Jt + N I I W cs + s Section: _I Block: Lot: '29 WRITE DIRECTIONS (from Mocksville) to PROPERTY:' Date home corners Ragged: )Jos s This is to certify that the information provided is correct to the best of my knowledge. I understand that any perinil(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if tine information subnnitted in this application is falsified or changed. I, also, understand that I am responsible for all cliarges hic u•red from this applications. I, licreby, give consent to the Authorized Representative of the Davie County IIealtln Department to enter upon above described property located in Davie County and owned b to conduct all testing procedures as necessary to determine the site suitability DATE �2' 2 �� 0S SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the follow ng: Lusting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EI -IS: Sign given `q5 fiftu Account N6- Revised DC1ID (05/03 Invoice No. 731 Defy 19tO5 Uzi Charlie Jones 336-859-0607 uec uua ua:ucp aavie county envnealtn vab rat arab `7 1IA "E COINN HEAT 111 I)t+P RTM'IE11TF Erivittrtlmentol Hectith SE ction "l 5- s S P. 0. ?l3az 134!L10 114Bgital 31 ttertt Mocksriike, NC 77MB :i , '� (336}75t-R74tt r 1'VEl'ltOVF.MEN'!/OrFRATIGN PERM.11" #: 99110(31726 Tax'1NfEH #): 5777-33-1382.24 Billed To: Campbell's Qualit o ProDarties, Inc. Subdivision Info: Stift Waters Phase T Lot # 24 Reference Name: Locatior!Addrm: K*y COI27006 Proposed Facility P=idenoe Pw arty Size: sw map i TC Number. u 3citft7paati.m PCr7riit DOES NOT aut}tbri�e the to is:r ion cifa Septic tank system ort any wastc"tcr system. An AM HORIZAII(IN FOR WASTEWATCR SYSTGIM CONSTRLKMON niust be obtained from this DCPartment prior 141 tt,e eonstructionlinstallation of a syslern or thr Nsuancc of build iig permit (in compiiauce with Article I t of G.S. Chapter ITA, W3stt W ler Systm s, Smion -V100 Sewa$e TmAtment and DTisposai Systems), Tws PERNM LS SUBJ C'T TO REVOCATION Er srM PLANS ( R THE vqTWwFwI USE CZUNGF YOUR WAMWATER SYSTEM C'DN TACTOR MUST SEE '[Til:i PERMTr BEFORE INWALLING SYSFEM. RcsidentWSFcriScatjon- BuildingT)q>c _ ►sPcopte ! - — NDedronms _ i#$aths _ Dishrrsshe.^ Garbage Disposal- E' CornmercialSfiecilicaflw: FacilkyTwx Washing Machinex Bas, rnent w/Plumbing: 0 AasertiertlNu PiunIh-1tg: llll #People ecoplidshin *Seats Industrial Waste: 0 Lot Sipe — — Type Walcr Sitpply _ design Wis1cwater Flow (GPI)) Sita: Nu jW, Repair ❑ System g-pwifications: Tank .Size/Aj'D GAL PUMP Tank _ , GAL. Trt xh Width' -Retell Depth � Li,car Ft. ol) Required Site Modifications/Conditions, IMPROVEMENTIOPYRATION f,--TMIT ]LAYOUT- APPROVED EI -FLUENT FILTEM RISYR(S) IFG •' UELOW FINISHED GRADE..--**NOTiCI4- ntad a rcpresentativtofthe r),%i:: County t-kaltb l)cplatm t for fatal itt3pcetion afthis .Vstem betwten 830 a.m. to 9:34 am. cr I : 10 pan. tho day orinstallation. i eltplrtxrc IS ()3G)751-It7t:D.`""" f �^ t- f Environmental Health $pr�iatist's Ssgtist�: � — y,_ -_ r-- — DCHI) 05199 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM & C Davie County Health Department 11AY 2 3 4VO5 EnvironlnentaiHeaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 J;NVtR&,,VMTAN (336) 751-8760 DAV7ECOUNTY� .***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.) 1. Name to be Billed ! I &ff Contact Person Mailing Address -{Q Am 6j46Home Phone City/State/ZIP & A1Q.�t!lffe, �G Z7L��l Business Phone 33&-785 in--- 2. Name on Permit/ATC if Different than Above V14 Mailing Address ��! T'' City/State/Zip 't//t --W-e- 3. Application For: —❑ Site Evaluation Improvement Pennit/ATC ❑ Both 4. System to Service: 19 House ❑ Mobile Honle ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative o 6. If Residence: # People It Bedrooms 3 # Bathrooms a)— RD-ishwasher [:]Garbage Disposal E Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type /# People It Sinks � Li _ 1. It Commodes # Showers # Urinals 3 It Water Coolers IF FOODSERVICE:. # Seats /1/ Estimated Water Usage (gallons per day) 8. Type of water supply: tib County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes E N0 If yes, what type? ***IMPORTANT. ** CLIENTS MUST COMPLETE TILE REQUIRED PROPERTY INFORt41ATION REQUES'T'ED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with TIIIS APPLICATION. Property Dimensions: C Tax Office PIN: # Property Address: Road Name _ 5f,11 (( (,t)4e#5 hyliy. City/zip aiJAP- e, k)G If in a Subdivision"" provide information, as follows: Name: �� �� b -W S Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PItOPERT1': A. -V 64 eq -f J-0 8o -f-*-AJ I& o-dD 96 1. 6 /z m k r' uJ4teo,!� 0,0,j Lei'-, aA4- l� &J /e �k hu'OSS -20� l ld- Aa -6c' a -J A -5k*' Date liome corners flagged: 3to This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use cliauge, or if the information submitted in this application is falsified or changed. I, also, understand that I ani responsible for all charges incurred from this application. I, liereby, give consent to the Autliorized Representative of the D1vic Con Jy Health De )artnicNt to enter upon above described property located in Davie County and owned by t� . to conduct al testing procedures as necessary to determine the site sui a ility. DATE �"3 �� SIGNATURIJ 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). Sign given Revised DCHD (05/03 5' V %A � Yd I" D&V9 Site Revisit Charge Datc(s) Client Notification Date: EHS: Account No. Invoice No. 7 ' DAVIE COUNTY HEALTH DEPARTMENT r Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT --rfm Account #: 990001720 Tax PIN/EH #: 5777-33-1382.24 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 24 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility Residence Property Size: see map ATC Number: 4093 **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/. ishwasher Garbage Disposal: ❑ Washing Machine/4 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply _ Design Wastewater Flow (GPD) 4 Site:, NewX Repair ❑ S System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.,Yo' i) Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Departme it for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1: 10 p.m.n the day of installation. Telephone is (336)751-8760.**** i Environmental Health Specialist's Signature: Date: 010 DCHD 05/99 (Revised) . " DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital street Mocksville, NC 27028 (336)751-8760 Account #: 990001720 Tax PIN/EH #: 5777-33-1382.24 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 24 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility Residence Property Size: see map ATC Number: 4093 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 CONSTRUCT ON IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: #Inll Date: b Z 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: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: .• M APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC "R Davie County Health Department R 2 6 21001• Environmental Healfft Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ,; (336) 751-8760 ENVIROP, i _E C.;,��h�. f Gc�ALTH DAVI ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed iuu.l' 11S 'C+4 .WC Contact Person DmA A D. C'^T�M(J�/c.l( Mailing Address 9000 �A�D�1 �/ 1' 1(r A4e- C . Home Phone 33(,,-795- 7 J ?!� 2— City/State/ZIP 1A &A o/'J- Jf#(L'.bt . AM -7,712-1 Businass Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: X House ❑ Mobile Home ❑ Business ❑ Industry Other Su ;vi ivd 5. If Residence: # People # Bedrooms 3-4_ # Bathrooms ;Z - a /Z fDishwasher Garbage Disposal Washing Machine ❑ Basement/Plumbing K Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply:( County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPER111 INFOM'd-TiiiN REQUESTED - BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: , Tax Office PIN: #, �D 77- 3 3 - I Ma • a t Property Address: Road Nameg W City/zip I A"Czi- d-CR7606 If in a Subdivision provide information, as follows: Name: `,`}-�� tl W mers Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: P.A 1+ +2 ul v 90 l , l urr/ (ern Cees 112 On. (e 0 tj 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 theavie County Health Department to enter upon above described property located in Davie County and owned betc to conduct all testing procedures as necessary to determine the site sui b lity. DATE �0 J !� I SIGNATURE J j 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. 11 -1- o Revised DCHD (07/99) Invoice No. 2? -`4 Y - h DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001720 Tax PIN/EH #: 5777-33-1382.24 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 24 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: —lU- "J Water Supply: Evaluation By: On -Site Well Auger Boring Community / Pit t/ Public 1--"' Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Sloe % HORIZON I DEPTH /b `� Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i - Structure i 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 U SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RA' REMARKS: Landscaae Position EVALUATION BY: // OTHER(S) PRESENT: 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 05/99 (Revised) rT APPLICATION FOR SITE EVALUATION/11,11'ROVEh1ENT PERMIT & ATC ` Davie County Health Department En Prironmenta/ Hea/ffi Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 t,j ,„ 4 n14P L,—, —1 21 EAP2 6 200f ENVIROt;i'; �CTEI DAVI(� .....:. .-�r.. ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED PROVIDED. Refer to the INFORMATION BULLETIN for instructions. AMP,19r ApAl`�y Pyr ' 'RVeU b. �-7;L{p6 1. Name to be Billed (iS etfi �L/V'l Contact Person }[<- it �C1 Mailing Address .9000 �A-nOti�Afl? � l 1 . Home Phone 33C — /95 4"2— - 374"2- City/State/ZIP ! 1 1l INtko/J-.'idLA1 �, / I _ �C 2712 7 / Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/zip 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: X House ❑ Mobile Home ❑ Business ❑ Industry 0( Other Su _ jvi5icN' S. If Residence: #People # Bedrooms 3 t i #Bathrooms 2 -- A '/z Dishwasher �( Garbage Disposal Ij(�washing Machine ❑ Basement/Plumbing I)( Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community B. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY iNFORi•UATiON REQIJES'➢ ED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: #, 5-177 3 3 - IM,, Property Address: Road Name City/Zip u'Atocs-'- 1X 7006 If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPER'T'Y: �-I0v e �L P A St r► G �� � OrUCeeEI '/z A (e 0 Name: S'i'p �� 067t r5 Section: t}SQ Block: Lot: I' -c? 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. 1, also, understand that 1 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the I,)avie County Health Department to enter upon above described property located in Davie County and owned by CiUiAlx(�ual� rU 'e to conduct all testing procedures as necessary to determine the site suitab lity. i' DATE 3j0�6, 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. a Revised DCHD (07/99) Invoice No.