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194 Feed Mill RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003516 Tax PIN/EH #: 9900 -EH -03516 Billed To: Steve & Ann Sessions Subdivision Info: Reference Name: ATC Number: 2476 A Location/Address: 194 Feed Mill Road -27006 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Sectio .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER TR TI IS.VALID FOR A PERIOD OF FIVE YEARS. \v Environmental Health Specialist's Signature: Date: / 5 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compli ce with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall t NO WAY be taken as a guarantee that the system will function satisfactorily for any given period o time. /10 AD la0C.�L-- A1Q u 0W16 -2) Septic System Installed By:�— Environmental Health Specialist's Signature: ate: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003516 Tax PIN/EH #: 9900 -EH -03516 Billed To: Steve & Ann Sessions Subdivision Info: Reference Name: Location/Address: 194 Feed Mill Road -27006 Proposed Facility: Residence Property Size: see map **NOTE * TTiis Improveme00peration 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 L 2S0 #People 2 #Bedrooms '� #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ LotSize Type. Water SupplyL Design Wastewater Flow (GPD) Site: New ❑ Repair System Specifications: Tank Size 1250GAL. Pump Tank GAL. Trench Width 3( Rock Depth 44, Linear Ft. 375 Other:AC Required Site Modifications/Conditions: k t iSTN-L- &A C-cQTt7 00- - � OFF t?ty .4'oe �'70� fin, IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFF UE T FILTER. RISER(S) IF 6 " BELOW FINISHED..GRADE. ****NOTICE: Contact a representative of the Davie C un ea h 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 i sta lat. n. Telephone # is (336)751-8760.**** En amt I Nooses CE � �TIW- --:?) T rcialist's tal Health ature: DCHD 05/99 (Revised) SPL Date: . Lae — Permittee's , i` DAVIE COUNTY HEALTH DEPARTMENT Name:,, Environmental Health Section P.O. Box 848 PROPERTY INFORMATION Directions! to property: ' L_ NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO: 1], rV6 Road Name: (" s' A 1p: **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 I I of G.S. Ch4pte-130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. TE ISSUED ��,� � !I RESIDENTIAL SPECIFICATION: BUILDING TYPE d(X C # BEDROOMS # BATHS �7 #OCCUPANTS GARBAGE DISPOSAL Ye� No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE LOT SIZE TYPE WATER SUPPLY Y' DESIGN WASTEWATER FLOW SYSTEM SPECIFICATIONS: TANK SIZE 1.4SL)GAL. PUMP TANK GAL. TREj REQUIRED SITE MODIFICAATTIIO^ NS_I,CC � �vJ„ 14 � )c_l 1__ IMPROVEMENT PERMIT LAYOUT )ITIONS 4 P^� S I'LL 4 L l� 1 �: c .3 -%WI, IFT / # SEATS INDUSTRIAL WASTE: Yes or No D) C t.JC-A% NEW SITE REPAIR SITE ►ter .1 WIDTHROCK DEPTH LINEAR FT. W-1 • D�..t:�,:�' .....q r~ :(- C (..1 C�t��- '�' �:?,E T,�.t J,.a% �,stt.t„, w.1•. Ill:. t.,iTt� L. L.1 ls~� **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. OPERATION PERMIT P::r" '+l SYSTEM INSTALLED BY: bbl A. i i� TION NO. OPERATION PERMIT BY: DATE: l ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) Pennitiee s '. ' DAVIE COUNTY HEALTH DEPARTMENT -T, Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: a Mocksville, NC 27028 Subdivision Name: - Phone #: 336-751-8760 Section: ¢ AUTHORIZATION FOR Lot: WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO: 7 6 A Road Name ' � �- �• `' **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 FornVAuthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pen -nits. (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 MOLD RESIDENTIAL SPECIFICATION: BUILDING TYPE ,MI - t . # BEDROOMS '" # BATHS `"` # 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) f. ' !. NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRE CH WIDTH �� ROCK DEPTH 1 ' J LINEAR FT. ' - % "r ` r ._ 1 Z L.Ll REQUIRED SITE MODIFICA446NS_/CONDITIONS , IMPROVEMENT PERMIT LA IJT- --- 7"11 . _. �* 4 rY;_r - Sit Srt� **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. OPERATION PERMIT J / _11) SYSTEM INSTALLED BY: [� `L) 4 t_I_ ��`'�1 L CJ 1( i i �v / �r a' �✓ 0l AUTrRZAT,ON NO. OPERATION PERMIT BY: DATE: **TE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE Wrfp ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A r;T1 RANTFFTI-TATTT-IFSVCTFMWTT.T.FITNCT1nNSATiSFACTORIT.VFnRANVr,iVFNPFRT0D0PTTMF DCHD 02/02 (Revised) `• DAVIE COUNTY HEALTH DEPARTMENT O IF (' p Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 VAR — i 2005 Phone: (336)751-8760 ar;r,?o,�C,IENTAC N;�lj, ON-SITE WASTEWATER CERTIFICATION FOR DIN °147Ecou, (Check One) REPLACEMENT ❑ REMODELING p--' RECONNEzCTIO Name: 7�V IFi7Z/I( �� 5. <b/U Phone Number: ��d ✓ � (Home) ,r� / -' o� �d V Mailing Address:�1�i' % �/ � ��(,� / f� � (Work) TAA_ , Detailed Directions To Site: / ,yd b o A A9 / 16 OA6 S S P P� , YlOt I S (F� �Y yJ7> � � �_D �c3% � �V�- (�lCm �� l d S/dS 47 .Sa i /�( �eSS/a �s r i rrx ��c G 7-1 ea &/Xf Property Address: F-e--�d 4t a 12,01 "tja4(e 4VIlf`ve�C � Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: e 551, Q�5 Type Of Dwelling: Date System Installed(Month/Day/Year): 125-6 Number Of Bedrooms:�Number Of People:_ Is The Dwelling Currently Vacant? Yes ❑ No ®Yes, For How Long? Any Known Problems? Yes ❑ No g,�-'44et,�in: QWy e- Ic, li)Qrzl.� ZJ r`C e % XW r - )e clY oe4' So ; k -9- 4AazcIeLf 0� /1 (� /�1��-P,J 6tkL � P -1210-d , Please Fill In The Following Information About The New Dwelling: ,4- i 74AII e.-�L AP Vv ' j� Type Of Dwelling: Ad(V P )1/`D� Number Of Bedrooms: Number Of People:l/, Requested By: c b C -UC' s- S4 (Signature) by , Requested:, For En iv ronmental Health Office Use Only Approved ❑ Disapproved ❑ -' ;2- If 7 k I/ AI` Pw�"-r I Ss s> 1 Environmental Health 'Me signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a I euarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. o;j Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $_/O O % Date: Paid By: Received By: / Account #: Invoice #: �l0 3 L ' DAVIE COUNTY HEALTH DEPARTMENT k . Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT ❑ REMODELING p`�' RECONNECTION ❑ C� Name: J % P (/ e /�- f �i�il( ��' s � �)f� /ll � Phone Number: r� �Cj (Home) Mailing Addressi Iq r e e6(& /t �'C & / �" -" F d U (Work) 1 I QCT r1�1 �( lr ' i;1 'lav 5�1ciS e 5_5ta A)-' n7 A, , /l Property Address: (f: 111 c- 41), �� !< <� � /? �� G� C'� �� ✓ � �c�v 41), ��r r - Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: .5a Type of Dwelling: Date System Installed(IViontli/Day/Year): ��?S� Number of Bedrooms:Number of People:_ Is The Dwelling Currently Vacant? Yes ❑ No D,- l Yes, For How Long? Any/ Known Problems? Yes ❑ No B /�I/f �!es; E-Ftp/l/ain: t'% (I) ,u F_. lP I ) ri /1;� o i DAVIE COUNTY HEALTH DEPARTMENT ✓� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Name ,<—JC ilC. NS' - - - Location Permit Number Date ZQ L- / y1 ,-/ , /" ,, l —enc/Of 4`fdc. Subdivision Name Lot No. Sec. or Block No. Lot Size ZQA�9-c House Mobile Home — Business __ Speculation I No. Bedrooms � No. Baths No. in Family Garbage Disposal YES NO ❑ Specifications 1, r S st Auto Dish Washer YES NO ❑ X2 S/� Auto Wash Machine YES NO ❑ "� 1, Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by *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. Final Installation Diagram: u System Installed by 1 ON l—lv1 Certificate of Completion '-f4Datey *The signing of this certificate shall indicate that the system described above has been installed in compliance with 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. gyp. m v aa.ei ' p � � S << R ORRELL TR V W �Y111y� m D � CD CD 46L " zz m s� o t � t 0 .."� 31 73 _ 277 - w 265 Z 5V2 L 253 7q a