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120 Graywood Court Lot 6• DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section c, ,Z P. O. Boz 848/210 Hospital Street Q Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001597 Tax PIN/EH M 5861-38-6328 Billed To: Marquis Building Subdivision Info: Redland Place Lot # 6 Reference Name: Location/Address: 120 Graywood Court -27006 Proposed Facility Residence Property Size: see map ATC Number: 3792 **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 flooa #People #Bedrooms 3 #Baths Dishwasher: I Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift 2'#Seeat�s Industrial Waste: ❑ Lot Size ' oL�ype Water Supply°, Design Wastewater Flow (GPD) Site: New Repair ❑ . System Specifications: Tank SizelOM GAL. Pump Tank GAL. Trench Widthr Rock Depth Linear Ft. Other: 1 f �- s Required Site Modifications/Conditions: i S�� e� C- Dt.�, 1`t Ib��i l-i�, IS � &z IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTERRISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Conta�esentative of the Davie County Health Dep ent 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.**** n 1 � 1 92. iQ Envirorrim tal Hea DCHD 05/99 (Revised) 50 SIS 4 LTjc'M„-3. Specialist's Signature: os� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. sox 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001597 Billed To: Marquis Building Reference Name: Proposed Facility Residence ATC Number: 3792 Tax PIN/EH #: 5861-38-6328 Subdivision Info: Redland Place Lot # 6 Location/Address: 120 Graywood Court -27006 Property Size: see map 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 wage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA U ION VA FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: Cd l ALI CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the sys has been installed in compliance with Article 11 of G.S. Chapter 13 Ze Disposal Systems," but shall in NO WAY be taken as a guaranteq ti rro given period of time. I lco SO RD > a:,7 Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) "-WrJA-S I on Improvement/Operation Permit 1900 "Sewage Treatment and . will function satisfactorily for any Date: May 19 04 08:42a _ Gordon Whitney 336 940-6947 ' APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health S& on P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IIWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. name to be Billed nailing Address.0 City/State/up 2. llama on Pornit/ATC if Different that Mailing Address 2- 70 0 (47 contact reraon L7_cy-AVO ,-t.1 / n( !:!t Home PhJ one - &, _u�r4-7 Bu.iness Phone S4-7 I SD City/State/zip 3. Application For: ❑ Site Evaluation AImprovement Permit/ATC ❑ Both 4. system to Ser. ice: �. House ❑ Mobile Home LI Business Ll Industry U Other 5. If Residence: Y People v-_ M Bedrooms_ s Bathrooms _2_ Dish.asher 11 Garbage Disposal I/iwashinq Machine LI Basement/Pluming t/no Plumbing 6. 2r Business/Industry/Other: Speei.fp typo t people / Sinks / Commodes / sh—ers t urinals A stater Coolers I£ FOODSERVICE: #t Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 0 County/City Cl Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCUMPLZTETHE REQUIRED PROPERTY INFORMATION REQUFSTED BELOW. Either a PIAT or SITE PLAN MUST BESUB.V1TTED by the client with THIS APPLICATION. Property Dimensions: �L"�' ` t gTC'&- WRITE DIRECTIONS (from Mocksvilk) to PROPERTY: Tax Office PIN: tl a0 Property Address: Road Name �ZQ 406!TJ `la _(fT.- 150: rT r City/Zip 140ypo( (� Vn—'- 1'ST If in a Subdivision provide information, as follows: vi Name: f�DL-AzID �t-IiCE Section: Block: Lot: Date Property Flat ycd: 105 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 is this application is falsified or changed. 1, also, understand that I am responsible for at/ charges incurred 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 roce ures as necessa ry to determine the site suitapyity. A//& DATE ! SIGNATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Ex)+ltjttg and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit charge Date(s): Client Notification Date: EUS: Account No. Revised DCHD (07/99) Invoice No. 9 X00 •. vf1GF�fFyT9 5r r c�UnlyF May 19 04 08:42a Gordon Whitney 336 940-6947 (OI &E21 A, o l --o -r (p �il��f�J�� �vtLs31�yC7 p.2 I)t` Q,)' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT O Davie County Health Department Environmental Health Section DEQ P.O. Box 848/210 Hospital Street 3 ?Ct�2 Mocksville, NC 27028 (336) 751-8760 ��R#NMFNTq/ OAVIE�p# H�ITy ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ! e V Contact Person % Mailing Address � (/1 � � Home Phone City/State/ZIP -2 `? Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: L"site Evaluation 4. System to Service: ouse ❑ Mobile Home 5. I£ Residence: # People _ Dishwasher U Garbage Disposal 6. If Business/Industry/Other: # Commodes ❑ Improvement Permit/ATC ❑ Both ❑ Business ❑ Industry ❑ Other r� # Bedrooms # Bathrooms .721 U Washing Machine Basement/Plumbing ❑ Basement/No Plumbing Specify type # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: ## Seats Estimated Water Usage (gallons per day) 7. Type of water supply: B-Gounty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? Beres ❑ No If yes, what type? 'IMPORTANT' CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: _��� 3Cf A-cl- 'S Tax Office PIN: # Property Address: Road Name / City/Zip WRITE DIRECTIONS (from Mocksville) to PROPERTY: L AE -al A.Z) If in a Subdivision provide in ormatia>a, as follows: Name: v NE Section: Block: Lot: _ OT !?Date Property Flagged: /r;2 ^73-- 0 �- 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. 1, hereby, give consent to the Authorized Representative of the Davie County Health Deep/artment to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitapility. 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). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Invoice No.