134 Eric Rd• Penrrittee s. DAVIE COUNTY HEALTH DEPARTMENT
d����D�
• Name: ZVI //1 T i� 1, Environmental Health Section FOPERTY INFORMATION
• �, :,� , j, P.O. Box 848
Directions to property: < ' - rF �' Mocksville, NC 27028 Subdivision Name:
r., Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
r ' WASTEWATER
Tax Office PIN:# -
SYSTEM CONSTRUCTION �+ /
AUTHORIZATION NO: � »° A Road Name: ` l 3 Yid''" C / 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
i
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS —..} # BATHS J # OCCUPANTS :;;' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or
No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) -5t–t' NEW SITE REPAIR SITE!
'^
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �" ' LINEAR F7::��r
REQUIRED SITF MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTBETW EN 8:30CT A -9 30 A.M. OR 1:00 -VE OF THE Dl 30IE COUNTY P.M. ON THHE AY OF INSTALL-ATIONOTELE HONE #R FINAL INSPECTION )75 87660. M
OPERATION PERMIT�r ```_
S INSTAL E+
s
0
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: " [
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY ESCRIBED ABOVE EEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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)
own, t/ `�/�
AUTH IZATION NO: 11 6 2 DAVIE COUNTY HEALTH DEPARTMENT
11- Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848
I Name: �%f/� C�/�'f?%f°%? Mocksville, NC 27028 Subdivision Name:
{ Phone #:704-634-8760
Directions to property: �I7, K -t/ Section: Lot:
AUTHORIZATION IDEWATER OR
x ecdy; '� /" ' SYSTEM CONSTRUCTION Tax Office PIN:# -
�l Road Name: i�C' Zip:
1\� •
**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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
91Y IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEDROOMS 3L # BATHS —/, <-# OCCUPANTS .5' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE/f # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY / i' DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH /'�" INEAR
REQUIRED SITE MODIFICATIONS/CONDITIONS
IMPROVEMENT PERMIT LAYOUT
r jai
,/ '7-7—
"CONTACT
7T
"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 (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED B
AUTHORIZATION NO. � OPERATION PERMIT BY:lLf! 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 05/96 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME W -A \t a (�. I�_v►� t...� PHONE NUMBER
ADDRESS _1 � �k Gk -,-L V,� SUBDIVISION NAME
�.M S u .\ 4 n C 2 `z o Z Ir LOT #,
DIRECTIONS TO SITE 6415- l • V% -0a l - T, It Fi- ChrL - I a� rrLK � Vkt.&
r/vn�= t.
uM.I
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDERClrw►�.r►'T-
TYPE FACILITY }1AtA NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY COLAKri SPECIFY PROBLEM OCCURRING Cooniv c Of !jr"'
DATE REQUESTED Li -13-04 INFORMATION TAKEN BY �L---
I--
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
AUTHORI7,AT'ION NO: 1 1 6 2 DAVIE COUNTY HEALTH DEPARTMENT
"
Environmental Health Section
PROPERTY INFORMATION
Permittee's�✓��'/
P.O. Box 848
Name: l/Z►''/ll
fO— 9%�fJ rr'
Mocksville, NC 27028
Subdivision Name:
Directions to property:
J3 - 'Z KA
Phone #: 704-634-8760
Section: Lot:
��AUTHORIZATION
FOR
WASTEWATER
x-1
j� � j1 /�
SYSTEM CONSTRUCTION
Tax Office PIN:# - -
,
!
!„Yt/ LG� %�
Road Name:)6rjr'L XcL • Zip: 76,0
**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 11 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
6 2 DAVIE COUNTY HEALTH DEPARTMENT
" IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name: C. ZejI p j Subdivision Name:
– Directions to property: __-, as /?/,/,Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
� �,✓0` j� � �E d �--� � o`-� t%
Rod Name:/—' rjC- I \� • Zip: '76,5?
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS '41 # BATHS _/, �# OCCUPANTS �5 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY ? DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANKGAL. TRENCH WIDTH.- ROCK DEPTH LINEAR Fr_-; n
I'
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
, . Mlxlx 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 INSTALLATIOti. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY
COQ Xl X/e "
lel
AUTHORIZATION N0. 1 /k a 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 AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05ft (Revised)
{ DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name: Subdivision Name:
Directions to property:.'_} `� .._. r "� f �'1•,� . Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
Road N/ ame:41"I C.. IR L, • Zip::
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED U SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
s
INSTALLING THE SYSTEM.
.w
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 'S/ # BATHS �!. C# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
T rkT QT7P TVPP WATPR QTTPPT V nPQTr.N WAQTPWATPR P! nW MPill NPW QTTP RPPATR QTTP
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK 0GAL. TRENCH WIDTH Z4 ROCK DEPTH LINEAR F
/nt �l�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
I IMPROVEMENT PERMIT LAYOUT
"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 INSTALLATIOtC TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY.
111 i` r "Zow, f l
/res C/
AUTHORIZATION NO. � OPERATION PERMIT BY: llee'l'l DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I1 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 05196 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WOR SHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME PHONE NUMBER` /b
ADDRESS `? Y�` _ SUBDIVISION NAME
SUBDIVISION LOT # /�--
DIRECTIONS TO SITE U "7 /L /71 -7 ,ff'
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED ! ____ _INFORMATION TAKEN BY ��