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3829 Hwy 64W Lot 17Permitteet s ; IIAVIECOUNTY HEALTH DEPARTMENT Name: "" C', ic; ti V If -:2 6' C) E? � Environmental Health Section PROPERTY INFORMATION L/ P.O. Box 848 Directions to property: v t P.O. r' `� Mocksville, NC 27028 Subdivision Name: ; *, �� < �� Phone #: 336-751-8760 r c t! �' Section: Lot: AUTHORIZATION FOR tU o�r WASTEWATER f G Tax Office PIN:# SYSTEM CONSTRUCTION t a c f - AUTHORIZATION NO: 0029 14 A Road Name: I � Zip: -� **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 Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compAiance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) /',!"'/� ��j'/ ''� I - o� "NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION (`-' � G' �i `t IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE 5 F # BEDROOMS 3 # BATHS D- # OCCUPANTS ')- GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No L, Ge C. ! -e LOT SIZE 'l TYPE WATER SUPPLY Ca DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE l� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK 'GAL. TRENCH WIDTH f ROCK DEPTH LINEAR FT. �Q OTHER of a i (10" k - a REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT � 6� ?° 11 a c� FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT �y SYSTEM INSTALLED BY: t6nJ/ A y -5d S � e s X01 r tory AUTHORIZATION NO. OPERATION PERMIT BY: / DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 A A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) r% C C-�` .52'1y,3 Permittees` ' a 5 ' D VIE COUNTY HEALTH DEPARTMENT Name: l—� 1- / `' ` ` / �L "`j +Environmental Health Section PROPERTY INFORMATION)1 j 1 P.O. Box 848 ;._ J .. Directions to property: t ' `' Mocksville, NC 27028 Subdivision Name: j Phone #: 336-751-8760 r , 4,4,. i, r; r.: (�;' Section: Lot: % AUTHORIZATION FOR WASTEWATER r' Tax Office PIN:# - SYSTEM CONSTRUCTION � j "e; I r I /I— . AUTHORIZATION NO: 002914 A Road Name: Zip: **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 I 1 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. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS 'A # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No 6 L1L GCI - LOT SIZE �/ TYPE WATER SUPPLY CC> DESIGN WASTEWATER FLOW (GPD) 5 U o NEW SITE REPAIR SITE E� SYSTEM SPECIFICATIONS: TANK SIZE GAL. POMP TANK _,4/ A,L. TRENCH WIDTH 3 I ROCK DEPTH ! LINEAR FT. OTHER Of a 5 6 /<�- ct REQUIRED SITE MODIFICATIONS/CONDITIONS: FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. W OPERATION PERMIT^ � Il iv \/ -5 SYSTEM INSTALLED BY: G H G' y , ON S i °c — AUTHORIZATION NO. Cr / L/ OPERATION 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) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME PeIVN WAS DIGS%C/ PHONE NUMBER V9Z" ZS33 ADDRESS 2f &S HW Gil ! 6 eK Sy` I1 SUB V S ON NAME /% LOT # DIRECTIONS TO SITE _ VV ®�Sl 16041 K Sle r_e— 0n4e 0/0 r DATE SYSTEM INSTALLED? ��' NAME SYSTEM INSTALLED UNDER �� ,�QNNe-l'1 TYPE FACILITY U6 L NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED TYPE WATER SUPPLY C4ut N SPECIFY PROBLEM OCCURRING 5Uy-I'Hee wwh✓ Cbm1hA 4so�lij / iyeS I DATE REQUESTED / 240 9 INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and th de SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 I am responsible for all charges incurred from this application. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND `.CERTIFICATE OF COMPLETION `Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number �+ y C.`Ji`%l ° <t Name Date t C! Location art F ; Ar.; i — Subdivision Name J� 14 -¢*;PJB i �' i Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO Z'J c Specifications for System: i 00 Auto Dish -Washer YES NO ❑ Z 00 It , - ` r " r . Auto Wash Machine YES NO ❑ Type Water Supply --- "This permit Void if sewage system described below isnot installed within 36 months from date of issue. t. Improvements permit by -' — `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 day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: Installed by 4"fk W I LL A' V: r Certificate of Completion /%Jf� �f Date`"' ~ `� *The signing of this certificate shall indicate that the system descried above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. APPLICANT INFORMATION C�.eov-5_.C*4 4k)nY '0 5 6 16S)kl Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Community Evaluation By: Auger Boring Pit PROPERTY INFORMATION 38aq Hwy 6[yw , Vocks,j 11t'41, -AIC Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Q_ 14 — Texture Texture rou G Consistence Structure G Mineralogy HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON / SAPROLITE / CLASSIFICATION 5 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: e3 LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: & Nom'✓i d)A< OTHER(S) PRESENT: oc 112S-1-1' 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 3y t 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 Mineralog 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 05105 (Revised) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note:- Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c., Permit Number AW Name'' �A� Lf aR0 y J►� Date (� 245 "� Location- �O' r j Subdivision Name OA KL& J D 44 t i G H T S Lot No. i 7 Sec. or Block No i. Lot Size loo X Zoo1 House Mobile Home _ !! Business Speculation', No. Bedrooms No. Baths No. in Family Garbage Disposal jj YES :p NO`1ZrSpecification NO fls for System: 900 Auto Dish Washer YES ��, i 700 k3 KSra,41[ Auto Wash Machine ,i YES NO ❑ i Type. Water Supply it�''� C`fl _ *This permit Void if sewage system .described below isnot installed within 36 months from date of issue. I�. Improvements permit by a n fi *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 day of completion. Telephone Number: 704-634-5985. 100 100 90 270 130 92 0 6 12 1 C i I X10 7 I � � N 4 I = 4 = ;g 38 = 37 = r 3 \. = 35 = 34 = 33 = 3 2 = 31 30 0 29 r- 0 0 _ o N 28 � T 17 18 19 20 21 22 24 �) 26 27 28 29 30 "A" I 00 lob' to 1 00 100 loo 1 00 l 00 101 80 10 4 100 0 0 i OAKLAND AVE. D" 16,96 05 105 22�� =2 .25 X121 33 83 �6 E„ 44 1 I 10f N 9 22 21 20 6 0 0 2 4 23 7 6 v 5 3v _ _ o> d' bi cr "' A 56 57 58 59 a� N 54 55 J s O �., N o 2 0 0 5 0 1f Cn 6 96 _2 22 81 8 -D CD $ 250 9 80 s .5.2 06 -6 244 14 06 z - u6 „ 19 95 19 12 '119 2 9 200 03 �o w 18 O II II 89 �� - 82 7 0 9 96 If y o Rl p 9 _ 26 �. �� o 9 8 6 a �ti� G�� 98 0 r� o `' c 6 r � 4 v Q e o °' 10 - C \ 94 ��. ,214 90 -J �78 c 16 15 93 co �_92 911 �, 5 �, 6� DAYM GOUNTY HE"SIH DEPARTMENT ENYMONME1SiT" HEAI,�II H SEGTIOhi PO BOX 848 210 HOSPITAL ST MOCKSVILLE NC 27028 June 15, 1999 Ryan Noble 14752 Cool Springs Rd. Cleveland, NC 27013 Dear Mr. Noble: Re: Oakland Circle Lot17 As requested, a representative from this office visited the above listed site on June 11, 1999. The purpose of this visit was to determine the soil/site suitability for the installation of an on-site sewage system. Based on the information provided on your application, the lot (17), was found to be unsuitable for the installation of an on site sewage disposal system for the following reason(s): Rule.1942(A)-Soil Wetness Conditions Rule.1941(F)3-Massive structure and expansive clay Rule.1945(a)&(b)-Available space Due to the limitations on these sites, this office is not aware of any modifications or alternative systems that can be implemented to upgrade the classification from unsuitable to suitable. Your application on these lots as listed above must be denied. You do have the right to an informal review of this decision by the Environmental Health Director of this office and also by regional staff of the Dept. of Environment and Natural Resources. You may contact this office to arrange for this further review. You may also wish to contact a private consultant to collect site specific data and submit this data to us for technical review. A site may be reclassified to provisionally suitable if written documentation, including engineering; hydrogeological, or soil studies indicates that a system can be reasonably expected to function satisfactorily. The data must show that: j A. The effluent(wastewater) will receive adequate treatment; B. The effluent(wastewater) will not contaminate any ground or surface water; C. The effluent(wastewater)will not be exposed on the ground surface or be discharged to surface waters where it can come into contact with people animals, or vectors. Finally, you have the right to a formal appeal of this decision if you file a petition with the Office of Administrative Hearings, PO Drawer 27447, Raleigh, NC 27611-7447. A copy of the petition must be received by the Office of Administrative Hearings within thirty days of the date of this notice. The hearing may be held in Davie County. If you file a petition for a hearing, you must send a copy of the petition to Mr. Richard Whisnant, DENR, Office of General Counsel, PO Box 27687, Raleigh, NC 27611-7687. I f you have any questions, feel free to call this office at (336-751-8760). Yours very truly, Clint Dorman Environmental Health Specialist • , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME /2,,, PROPOSED FACILITY SUBDIVISION SECTION LOT DATE EVALUATED 4� e PROPERTY SIZE ROAD NAME Water Supply: On -Site Well Community t� Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: o< LONG-TERM ACCEPTANCE RA REMARKS: DCHD (01.90) �o EVALUATION BY: OTHER(S) PRESENT: LEGEND Landscape Position " V 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 Landscape position HORIZON I DEPTH Texture group Consistence r�r.��•rr�r—��e�� Mineralogy HORIZON 11 DEPTH Texture group Consistence HORIZON III DEPTH Texture group lw�FVWN. ".7 - Consistence Mineralogy HORIZON IV DEPTH Texture group Consistence SITE CLASSIFICATION: o< LONG-TERM ACCEPTANCE RA REMARKS: DCHD (01.90) �o EVALUATION BY: OTHER(S) PRESENT: LEGEND Landscape Position " V 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 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS■■■s■■■■■■■■■■■■■��■■�■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■tl■Iii■■■■■■■■■■■\' ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ SOMME ■E■E■ MOOSE ■E■EM ■E■E■ ■E■E■ ■■Sri■ ■■m■■ ■■■O■ ENE ■■m NEEMM■■■M■■EME■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ SEE MEMMEMMENNEN0 ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■ ■■N■■■■M■S■M■■■■■ i■MN■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■OMOOM■O■■ ■■■■■■■■■■■■■■■■ ■■■N■■ ■■MN■■ ■EEM■■ ■E■■M■ ■■M■M■ ■■EM■■ MEMS■■ ■■■■M■ ■■■■■■ ■■■■O■ ■■MEMS ■■■■■■u ■OMM■■ ■■MEM■■■ ■■■MM■■■ ■■M■■■■■ ■■■■NEEM ■■■■M■■■ ■NOON■■■ ■M■■■■■■ ■MESS■■■ ,1■■■M■■■ MEMEM■■■ ■■■■FA■■■■■■■ ■■■RA■■■■■■■■ ■■MENEME■■M■■ RA■M■■■■MM■■■ NEEM■■■■■M■■■ ■■■■M■■■■■■■■ ■■N■■■■■■■■N■ ■■■■■■■■■■■M■ ■■■■■■NEEM■E■ ■■■M■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■M■■■■■ ■■O■■■■■■■■■■ ■■■■■■■■■M■■■ ■■■■■■■■■■■N■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ., .i.0 o.0 mr riatN 1 rt AINI 11!t All; Davie County Health Department Eavir vamental Health Section D P.O. Box 848/210 Hospital Street Mockaville, NC 27028 MAY 2 7 1999 (336) 751-8760 1:11111anAIRIMTA ***n1P0RTANT*** THIS APPLICATION CANKOr BE PROCESSED UNLESS ALL RE U-- COUNTY INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed -1`(A., �� % Contact Perrsoon� ` E& An/ Nbbk Mailing Address Some ptsoi�eyJ� City/state/LIP Business Phone( , 3 3 �o� 969 .2/,/ Name on Persalt/ATC If Different than Above Nailing Address Application For: • ite Evaluation System to service: muse ❑ Mobile Home It Residence: tm'DI asher City/sta Lip rovement Permit/ATC ❑ Business ❑ Industry # People ,3, 61_ # Bedrooms 0 Garbage Disposal 0Yf hang Machine 0 Basement/Plusbing 6. If Business/Industry/other: Specify type ❑ Other # Bathrooms 2- 0 Basement/No Plumbing # People '# Sinks # Commodes # showers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: ounty/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system U intended to serve! 11 Yes If yes, what type? "* *IMPORTANI "* CLIENTS A1UST CVAIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either s PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: f Tax Office PIN: Property Aldress: Road Name City/Zip If In a Subdivision provide information, as f (lows: Name: o,� L, -J V'- " Section: Block: Lot: WRITE DIRECTIONS (froom Moclulville) to PROPERTY: (mac T o �yi ck1d'�.�� S11 c Ari K, %P— 6 a..,// Hue. 6 aka: �� lL ► SGon� Qt�o.� L,-P4- DateProperty Flagged: �GT_ This is to certify that the information provided is correct to the best of my knowledge. 1 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 roponsi8lefor all Charges incurred fiver this appUcadon. 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 suitabili ,, j DATE 7Z6-)�L 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). Revised DCHD (07/98) Account No. Invoice No O