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244 Chestnut Trail Lot 18-19 (2)Davie Coun�� Health Department 4 r ' V:,En` i onmental Health Section P.O. Bot 848 .sus, 210 Hospita_1 Street O Courier # : 09-40-06 Mocksville, NC 27028 Plione: (336) - 753 - 6780 ON-SITE WASTE`VATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: V'/6'����e /— Phone Number Mailing Address: 4 � (r4f e 1.:17 ?dry/' Detailed Directions To Site: Fax (336) - 753-1680 me) ork) Property Addie: Please Fill In The Following Information About The EWSTIVG Facility: Name System Installed Under:_ Type Of Facility:us Date System Installed (Month/Uate/Year}:�/�%� Number Of Bedrooms: Number Of People. Is The Facility Currently Vacant? Yes If Yes, For How Long? Any Known Problems? Yes Co)If Yes, Explain: Please Fill In The Follov Type Of Facility: Pool Size: XRequested By: { ig ature) Approve Information About The /NEWFacility: i� M/ 1'755/ Number Of Bedrooms umber of Pe- le Environmental Health Specialist - A Other:. .ate Requested: For Environmental Health Office Use Only Date: *The signing of this form by the Environmental�Iealth Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period oftime. Payment: Cash °Check, Money Order #, Amount:$ Paid By: Received By:_ Account P-: Invoice #: Davie County GoMaps 017 1:2,257 0 0.0175 0.035 0.07 mi 0 0.03 0.08 0.12 km ' Sources; Esr� HERE, DeLorme, USGS, Inlermap, INCREMENT P, NRCan, Es �ftij Japan, METi, ESK China (Hong Kong), Esri Korea, Esri (Thailand), Mapmylndi NGCC, ©OpsnStrsetMapcontributors, andthe GIS User Community Davie County G •�- DAVIE COUNTY, HEALTH DEPARTMENT (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absor .tion Sewage,Disposal System - G.S. Chapte 130 -Article 13C) OWNER OR CONTRACTOR �c7' �-�,. DATE f -i 9Mi PERT LOCATION N° 14 1 / S. R. NO. SUBDIVISION NAME k%r !!- . LOT NO. /I SECTION OR BLOCK NO. NO. BEDROOMS I.- NO. BATHROOMS r? GARBAGE DISPOSAL UNIT YES NO AU`P0. DISHWASHER YES NO; ❑ AUTO. WASH. MACHINE YES NO SITE SUITABLE YES ❑ NO SIZE OF TANKo? ; C? gal. NITRIFICATION FIELD d a sq. ft. fir DEPTH OF STONE IN LINES: WATER SUPPLY: Individual -Public ❑ IMPROVEMENTS PERMIT BY CERTIFICATE OF COMPLETION By �E migP1d6 (8116173) *Construction must comply with a LOT AREA House Trailer Two Bedroom House Three Bedroom House Four Bedroom House /f4- 2- 0 Q INSTALLED BY 800 Gal.. 400 Sq. Ft. 800 Gal. 600 Sq. Ft. 900 Gal. 900 Sq. Ft. 1000 Gal. 1200 Sq. Ft. - ./ eo 1 bate other applicable tate and local regulations 17 j7- ��F� � - /✓15� F�ii -�? ray: APPLICATION 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: 0 Site Eva] uation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both Type of Application: DNew 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 BULLETIN for instructions. APPLICANT INFORMATION / Name Ec/ L-/�= 1 Sit/ Address 1'3 City/State/ZIP _ ��'�-►ctr _ C 27 d �6 Email Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION Contact Person Home Phone _ 3 7sr, - ko - 5 q -Z % Business Phone 7 Y,' - FK2 70;; _.- Email: *Date House/Facility Corners _ NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑P]at(to scale) (Permit is valid for 60 months with sit plan, no expiration with complete plat.) Owner's Name . r- 2 l i t A �` Phone Number Flo Owner's. Address— oqw cf;tZ44 -i � twl ( WA - City/State/Zip C,,/& 0 Z Property Address fi / / City Lot Size Tax PIN# t' J^ Subdivision Name(if applicable) Section/Lot# Directions To Site: On ZP L,, _ /_ P - _ _A If the answer to any of the following questions is "Yes",suppor%locumentation must be attached: Are there any existing wastewater systems on the site? _Yes Does the site contain jurisdictional wetlands? _N Are there any easements or right-of-ways on the site? _Yes Yes /Ilg Is the site subject to approval by another public agency? /�T Will wastewater other than domestic sewage be generated? —Yes Yes /No IF RESIDENCE FILL OUT THE BOX BELOW d LCAL # People # Bedrooms # Bathrooms Basement: []Yes ❑No Basement umbing: ❑Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW 'rf /�­X4 Garden Tub/Whirlpool Li Yes ❑No Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Accepted []innovative ❑Alternative []Other Water Supply Type: ❑ County/City Water 0 New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No 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 permit(s) IP(s) or CA(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. Permits issued will expire 5 years from the date of issuance. 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 I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Revised I1/16 Invoice #