223 Maplewood Ln (3)DAVIE COUNTY HEALTH DEPARTMENT J v;
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900241 Tax PIN/EH #: 5863-69-1281
Billed To: Craig Carter Builders, Inc. Subdivision Info:
Reference Name: Location/Address: Rooster Trail -27006
Proposed Facility: Garage Property Size: 330 acres
ATC Number: 2991
"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
l
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: Basement/No Plumbing:
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 171
Lot Size c� O Type Water Supply 4: ' // Design Wastewater Flow (GPD) oe;V Site: New4Fr,,, Repair 1:1
System Specifications: Tank Size/� GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width i," Rock Depth Linear Ft
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:
DCHD 05/99 (Revised)
Davie County Health Department
r
4 cif Environmental Health Section
_
.r ¢�+FiY��+l® P.O. Box 848
�11 Street 210 Hospit<
Q flit �I Cotuier 4: 09-40-06 F
— - Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax; (336) - 753-1680
ON-SITE WASTE`4VA KATION
(Check One) Replacement C2emode Reconnection
Name: i0. iLC/� a..[/5 --2f-., Phone Number (Home)
Mailing Address: 57f ft -1114 e. < WIWI, (Work)
Detailed Di eS,tions To Site:
Property Address: 3 .,'a ✓ re- .ve
-fM u6 ,!+ p
Pleas e ill In he Following Information About The EXISTING Facility: 5��
Name System Installed Under: /' L.br �015 Type Of Facility: ,V qe
.J
Date System Installed (Month/Date/Year): 140 ,�9,9- e?G V / Number Of Bedrooms:____(:�) Number Of People:_
Is The Facility Currently Vacant?/Yes No If Yes, For How Long?
Any Known Problems? Yes //N� If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 4 6 0 Number Of Bedrooms: 49 Number of People
Pool Size: Garage Size: 5p2 'K � g Other.. /—o,e-1
Requested By: Date Requested: 0»
For Environmental Health Office Use Only
Approved _,,>bisapproved
?a r
Comments: f , %�.�1 ,�'�' t> Y !` �Z S "3 !�/a 1 C �`�-/ S %c�v� , �� r41�
Environmental Health Specialist Date:'
*The signing of this fonn by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended orj' ited) that the on-site wastewater system will function properly for any given period of time.
Payment: Castf ck oney Order # c2616275 Amount:$ IF O. (. Date: ,b
Paid By: Received By:
Account #: Invoice #: 6 -r-- �3773
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