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249 Gilbert RoadDavie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005528 Tax PIN/EH #: 5851-26-8843.1 Billed To: Sugar Valley Airport Subdivision Info: Address: 249 Gilbert Road Location/Address: 249 Gilbert Road -27028 City: Mocksville Property Size: v 3 Reference Name: Susan Park Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: New ❑Repair~❑Expansion Permit Valid for: ❑ Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) £x ,.5�t�y Design Flow(GPD): a40 Type of Water Supply: ❑County/City Nell ❑C'ommunity Well Site Modifications/Permit Conditions: As stated in 15A NCAC :t8A.19f9(5)deeep.�c Systows may also be Use( Plan 2caS4_-,M.eC4+ 4U sep�r� Environmental Health Lp.11-06 Initial �Ory� LT Date Zo' oZ KO DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005528 Billed To: Sugar Valley Airport Reference Name: Susan Park Proposed Facility: Residence ATC Number: 5105 Tax PIN!EH #: 5851-26-8843.1 Subdivision Info: LocationiAddress: 249 Gilbert Road -27028 Property Size: Site Type: 21gew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. , , ,A _,fid d w '0-Dtc V -e5 I-' .'07r9 ...— Residential Specifications: # Bedrooms 14 # Bathrooms A # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Lot S&e 1.0 7��rt Square Footage(or Dimensions of Facility) r-i�I lrrd � � Specifications Type of Water Supply: ❑County/City gQ11 ❑ComAumty Well 06 Design Wastewater Flow (GPD) Tank Size /I GAL. Pump Tank -GAL. &0:5-r Dns/Other: Width 3(o Max. Trench Depth 3G Rock DepthLinearFgt./� �`+s stated in 15A NCAC 1.8A.1968(5` aS LOK "Ci van ons/Other: d i3 , d CE�1�'c�-djv�-rrr.-n-rP7--ariv a is Faj'c Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m..yonn they day of installation. Telephone # (336)751-8760. f' U.k A to Environmental Health Specialist Date:����o'j(,--/(1 f DCHD 11/06 (Revised) DAVIECOUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 Account #: 990005528 Billed To: Sugar Valley Airport Reference Name: Susan Park Proposed Facility: Residence OPERATION PERMIT Tax PINfEH #: 5851-26-8843.1 Subdivision Info: LocationlAddress: 249 Gilbert Road -27028 Properly Size: ATC Number: 5105 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type: S.T. Manufacturer Tank Date. Pump Tank Size System Installed By: GPS Coordinate: DCHD 11/06 (Revised) E.H. Specialist: Tank Size Date: Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005528 Billed To: Sugar Valley Airport Address: 249 Gilbert Road City: Mocksville Reference Name: Susan Park Proposed Facility: Residence 0%&fel e -X W-i�N Tax PIN/EH #: 5851-26-8843.1 Subdivision Info: Location/Address: 249 Gilbert Road -27028 Property Size: 'e a **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: ew ❑Repair ❑Expansion Permit Valid for: C75 Years ❑No Expiration Residential Specifications: # Bedrooms_q_ # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) yifs105 Design Flow(GPD): I � D Type of Water Supply: ❑County/City e Community Well lis stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: accepted Systems may also be used System Type LTAR Initial C - / 7 5— Repair Re air D.17S Site I Ian %AJ4E Ide Environmental Health Specialist i.p. 11-06 10 `r, k 10e.We rt. �►�'� v i Date -1-36—(o . Apprf;cation For: I/Site Evaluation/Improvement Permit Type, of Application: ❑New System ❑Repair to Existim ***IMPORTANT*** THIS APPLICATIONCANNOT INFORMATION 1S PROVIDED. Refer tothe INFO APPLICANT INFORMATION Name to be Billed Billing Address City/State/ZIP Name on Permit/ATC if Different than Above Mailing Address Call WW TC) ❑ Both 0 f Existing System or Facility 4E REQuiRED Contact Person Home Phone."--I 'I I P, cell PROPERTY INFORMATION TP I *Date House/Facility Corners NOTE: A survey plat or site plan must iccompany this application. Included: UKite Plan ❑Plat(to scale) (Permit is valid for 60 months 'th site plan, expiration witcomplete plat.) Owner's Name Phone Number Owner's Address City/State/Zi Z79 Property Address City Lot Size Tax PIN# 451- Zb -bi'U. I Subdivision Name(if applicable) - Sect,/io�n/Lot# ^ n Directions To Sitg: a, as Pa trM t Mn 4'L► A n;Y Y>id e- 6 If the answer to any of'the follo(ving questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes EKo Does the site contain jurisdictional wetlands? []Yes U�N6 Are there any easements or right-of-ways on the site? ❑Yes P o Is the site subject to approval by another public agency? ❑YesQo Will wastewater other than domestic sewage be generated? ❑Yes W1101, IF RESIDENCE FILL OUT THE BOX BELOW # People 1 # Bedrooms I # Bathrooms �_ Garden Tub/Whirlpool ❑Yes )No Basement: ❑Yes Ao Basement Plumbing: ❑Yes Mo IF NON -RESIDENCE FILL OUT THE BOX BELOW 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: 2MConventional ❑Accepted ❑Innovative ❑Alternative ❑Other i Water Supply Type: ❑ County/City Water ❑ New Wellxisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo 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 any permit(s) or ATC(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. 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 locat' g and flagging or st the se/facility location, proposed well location and the location of any other amenities. POrty owner's or owner's legal representative signature Site Revisit Charge [Date(s): ,4e � W XS-Ldo' �y y- f1�'73�(S' lient Notification Date: RAT I I 11 1 mSO ill I N I Ilditl IAI ii+MINVE Call WW TC) ❑ Both 0 f Existing System or Facility 4E REQuiRED Contact Person Home Phone."--I 'I I P, cell PROPERTY INFORMATION TP I *Date House/Facility Corners NOTE: A survey plat or site plan must iccompany this application. Included: UKite Plan ❑Plat(to scale) (Permit is valid for 60 months 'th site plan, expiration witcomplete plat.) Owner's Name Phone Number Owner's Address City/State/Zi Z79 Property Address City Lot Size Tax PIN# 451- Zb -bi'U. I Subdivision Name(if applicable) - Sect,/io�n/Lot# ^ n Directions To Sitg: a, as Pa trM t Mn 4'L► A n;Y Y>id e- 6 If the answer to any of'the follo(ving questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes EKo Does the site contain jurisdictional wetlands? []Yes U�N6 Are there any easements or right-of-ways on the site? ❑Yes P o Is the site subject to approval by another public agency? ❑YesQo Will wastewater other than domestic sewage be generated? ❑Yes W1101, IF RESIDENCE FILL OUT THE BOX BELOW # People 1 # Bedrooms I # Bathrooms �_ Garden Tub/Whirlpool ❑Yes )No Basement: ❑Yes Ao Basement Plumbing: ❑Yes Mo IF NON -RESIDENCE FILL OUT THE BOX BELOW 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: 2MConventional ❑Accepted ❑Innovative ❑Alternative ❑Other i Water Supply Type: ❑ County/City Water ❑ New Wellxisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo 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 any permit(s) or ATC(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. 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 locat' g and flagging or st the se/facility location, proposed well location and the location of any other amenities. POrty owner's or owner's legal representative signature Site Revisit Charge [Date(s): ,4e � W XS-Ldo' �y y- f1�'73�(S' lient Notification Date: I x. 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