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2034 Angell Rd (2), .. . . . , . . . , ,: _ _ _ ,... , . . . . _ , .- , .. ,� ,. , , ` , , :, Permictee's r�� j ,, --t'� �' D�, VIE COUNTY HEALT�H DEPARTMENT �� �'�`� �� v�� Name: t• .��I���� �.�' .�';=�%-�/ 1/ � Environmental Health Section '� PR OPERTY INF ORMATION , . _ -• I �I � �l� P.O. Box 848 Directions to property: � Mocksville, NC 27028 Subdivision Name: � ����r���.�� ��� ; �(� ���� �.' � Phone #: 336-751-8760 I' Section: Lot: ' � �� �� AUTHORIZATION FOR ��.� . t��� �(� r� ,`,�',>-5 7,�%�.�'l�.� 1U � WASTEWATER Tax Office PIN:# - - , SYSTFM CONSTRUCTION � �' ,, i , r�;—� AUTHORIZATION NO: ��` ��``� A Road Name: ���"�j��'L�-�-- ���} Zip: E-- ��-�'�� **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should bc presented to the Davie County. Building Inspections Office when applyin�.for Building Permits. (In compliance �th Artic�e l l� G;,$,.Ccttapter�30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) rs��r,s� r.._. _ '"� ��'� TH SPEC[ALIST ` DAT ISSU� ***NOTICE*** TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. � �.....,- • ,�.�,lC '.., � RESIDENTIAL SPECIFICATION: BUILDING TYPE k�"�`''r"' # BEllROOMS � # BATHS r' # OCCUPANTS '�' GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TY E # PEOPLE # PEOPLFJSHIFi' # SEATS INDUSTRIAL WASTE: Yes or No Ln�n1'1/11 � �� ��)���l-r�f/ �� �/� LOT SIZE -'v"_1' TYPE WATER SUPPLK /l�' / DESIGN WASTEWATER FLOW (GPD) L-r'���`-' NEW SITE REPAIR SITE v `/ ,r SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDT� ROCK DEPTH � LINEAR Ff. / LU , OTHER ( � �^ REQUIRED SITE MODIFICATIONS/CONDITIONS: �� � �� F'�'�� ( '+""`-"' ' � ��� ��i' �'"� �y'� �, IMPROVEMENT PERMIT LAYOUT 0 **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 THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. I OPERATION PERMIT SYSTEMINSTALLEDBY:_��JLW�,�N' -�VN� ��T��� � I`�`O�S�= . �. �x3c��2 � S�� . s �'��c ���-' ,� -r- 2! I� � � � AUTHORIZATION N0. APERATION PERMIT BY: DATE: � � *'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S ESCRIBED ABOV 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. I DCfID 02/02 (Revised) . , . ' . � DAVIE COUNTY HEALTH DEPARTMENT � �:ti,, ; ;. �(r�� �, tt ��( � Environmental Health Section � f j,� .' _� �� PO Box 848/210 Hospital Street /� ' "'� �T—� Mocksville, NC 27028 �,,�� . . .�``:�. , f� h� � � C�Q3 Phone: (336)751-8760 Cl�- �ATER CERTIFICATION FOR DWELLING ❑ REMODELING ❑ RECONNECTION ❑ Name: �Q/'"`�S V• �C� C-c�S Phone Number: 3 3l0 %� 5 d S i� (Home) Mailing Address: �l8 Z)XC/�� �/����/� (Work) Lti C/1 S�x� �z l�vn /ll G a 7/ c73 Detailed Directions To Site: CO � � / �o�'t/� z� /�nn � L� �C�C� ^ �c U'rL, - - -- - - � — Property ' L-C-- G E���nvl-IS tfil?� � ��" ►"L�.�P — � Please Fill In The Following Information About The Existing Dwelling. , L� • � f� Name System Installed Under: �����e Type Of Dwelling / Date System Installed(Month/Day/Year): � y Number Of Bedrooms:, �_Number Of People: Is The Dwelling Currently Vacant? Yes� o❑ If Yes, For How Long? Any Known Problems? Yes ❑ No LM' If Yes, Explain: Please Fill In The Following Information About The New Dwelling. �GtNtc�z �/' Type Of Dwelling:YrlaG�c.��Ct r 77L�►'?1 t� Number Of Bedrooms: � Number Of People: � Requested By: ��� �� '�_� ��(J�l�-'- Date Requested: 3 - � � � �`� (Signature) For Environmental Health Office Use Only � ���,3Y� Approved ❑ Disapproved ❑ Comments: Environmental Health ��1 ��1.,.'`... '"'The signing of this form by the Environmental Health�t'ff is in no way"�nterKied, nor should be taken as a euarantee(extended or limitedl that the on-site wastewater svstem will function nroverlv for anv Qiven veriod of time. Payment: Cash ❑ Check ❑ Money Order ❑# Amount: $ '� �� Date: Paid By: Received By: Account #: �� � � Invoice #: � �7 {� � _.`.A . ... . ti , • DAVIE COUNTY HEALTH DEPARTMENT p " � � Environmental Health Section � PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 /�-�` �-�� �'� �� .����. �" ON-STTE WASTEWATER CERTIFICATION FOR DWELLING '`��� •,, (Check One) REPLACEMENT o REMODELING ❑ RECONNECTION o Name: �/ �- Q I` C � S V • �h- � C-c..�S' Phone Number: � 3�P � �' � � � r� � (Home) Mailing Address: ��c�S' T�xCl�7��' �/-Y u�- "—"�", (Work) y . (1J � r� ,<-{-,�, ` ti--, %w�-,-� /� /�-.: �? %/ � �;�� Detailed Directions To Site: � U� /v�'��iz Z�d f-'�/ i�i ?r' l� /c��f("� -- Z�-< !"�'t. , ' , (G � --- _ C�c�/r z�' ---� �o ll:� �� �� / y , ��..� -� _ �- �,�,,,,- / ��,��, l., . , , 1f;/1 if� lJi i �t��c/� ��:i`�' ifS C'(/�c`�r°- �!1, PropertyAddress: -=�a�'=��=<�r' ,�"'7/"!�/(�t_[� t�'-��rl� ______ _ � � --Q'�"�"= /✓o� GSrA�L/S flll/� Please Fill In The Following Information About The Existing Dwelling. L �-- . �l �`-� Name System Installed Under: �� rn�3 �� Type Of Dwelling Date System Installed(Month/Day/Year): �`� Number Of Bedrooms:�Number Of People: Is The Dwelling Currently Vacant? Yestp/�10 0 If Yes, For How Long? Any Known Problems? Yes ❑ No � If Yes, Explain: Please Fill In The Following Information About The New Dwelling. �''c� ��-1z Type Of Dwelling: V1� �� .� � l�i ��cv'}� �� Number Of Bedrooms: � Number Of People: � t � � � � �� Requested By:� :�'1 !'� . � r� 1 ,�'i e.: P` � ��"'1 �' ! • ���f,�-. Date Requested• � '" �='� i=----�- � y . (Signature) ) For Environmental Health Office Use Only ) ��'''� Approved 0 Disapproved ❑ �'h /2 ���- j r �- �__ ��� �� S� c��.., Environmental Health Specialis � �. / \ _----' Date / �" ` i , ; i 1 •:.��a t. . r � �`3•. 5 '"'The signing of this form by the Environmental Health�Staff is in no way�intend'ed, nor should be taken as a guarantee(extended or limited) that the on-site wastewater system will function properly for any given per'iod of time. . � � Payment: Cash ❑ Check ❑ Money Order ❑# Amount: $_ a.-� Date: Paid By: Received By: Account #• � � � �..,._.,._ , � �/ � � . , 4_ �,��. � V" '� Inpoice #: _ . . , ,,... _. . _ . . _ . . . T F,,. -_. ... _. . --..,�,„. __ ,. ... , J . � . ,� . � .,,_ .. . . .. .. . .. . . . _. . . . � , � � i •• _._._...r-..._-_—....._....�,� � ., w � i �_ . ,. .. — �__ ,. _. .._ _ , ' ' v >' O r_�"�� : ��:_�_ �< , DAVIE COUNTY HEALTH DEPARTMENT .`. IMP�OVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c . Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name ��.m�� jCirni?�cs« _.' Date.���� �P��� �:;l�� Location ��C'�/ f(/tlit.7// �% . :>•..� � NG, f� c /G �.� �. C% %Y7 i[ r O/`� �r F;� ,CS'.� i v�rcr .c ' � �/��>f:. Subdivision Name Lot No. _ Sec. or Block Na Lot Size House Mobile Home `-�"'� Business Speculation 3 No. Bedrooms � No. Baths � �y Garbage Disposal YES p NO ❑ Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES ❑ NO ❑ Type Water Supply �'� uN r� N.o. in Family Specifications for System: /C�Uv������ �``-"�� , . „ ZaCJ .'C 3 h /Z S/"n/vd. y'tS��?c J:_� �u�rC.�ff iC `This permit Void if sewage system described below. is not installed within 36 months from date of issue. � r '� �i ��N r Improvements permit by �� ,�"}���''''"- S}�A�``'a' . �.;.•_�.._ '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. . , ,r Final Installation Diagram: System Installed by .,;,.y ;� �� f �'� "' "r'/ Y<-� !t ; �1 h' _ ;1,/ . � f....-. . ^,' ... 4� / . � Certificate of Completion , l <�'�li'� Date '��� �� "The signing of this certificate shall indicate that the system described above has been installed in compliance �th 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. � `:��� �, �� �"�'� � _�,, � ��.';,.�� �� �; �b� ` �� � � �_, ��;� � � � �� � ."` � t �Y � ° �, � a� ��R x�*'��� � a ��' ��g � �a�,� ���` ^ ' `�� y'� '�� � i h u � � ' � a s �f ' `"� �.°,� "° � � � � K � k��'� � ���, ,�g �.-'������, - ��"r "9 "� '� ".�, .��; . ,.a t g �`�`�'����'�3 � u �� ��� .,z... �.,�. ��� A a ,. r����, '" ��,.. ;� �,�� � "- k"�,�, •��.�� �, ''a 4 , ct g�t� "6�`,�' �u ��. „ ��d���h, � � � � � � �� '3� d�.� �! � 7�`a'� , � �{ � � �'a�s � � ,.§� w�{ ` k ( z YL� : .� �1_ � 4 g � A c�HI�'� �: �� � y�/ '�£ �` & �i g:�h +TM a 353 � a ��a ���9 ,� � �`��� n` ' � � a z� � 4 :, g a. � ,�� �" ' ���, � ����� ��� � ���� � � ��a, k � ,. d ' $+� c, � � �s � s 9M d�� � ���� Y����,�yk �� r%� � � � ��� � � » � � � ,�,�,gre �`�� � �,• ' '�` � i � $ < � ; ; �� � �r,� e �.� � > � �F �" ���� �� , , ��" �„� '�e� ��� � '� �� � � r� � ��� �' �`� � � �' x e � � .".Y� ��W Y�% � � a�l � #,,,�� R 5 . ,� � � � � � 9 � � �"� ��� ��� ���� �, �A p� �:.: � �`< ����� ^�� . � # �� : � � � ���2��� �� �� »�� �`,_�` ������� ,� �,� ��`� ° �� R'" a =�`� g�` M �'�a: z, �; �� . 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