123 Friendship Ct,Permittee's r/ d� DAVIE COUNTY HEALTH DEPARTMENT
m
Nae. be`I' A her Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: ` r f ' Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
? `? J WASTEWATER
j: � Tax Office PIN:# - -
- SYSTEM CONSTRUCTION
a _
AUTHORIZATION NO: 003040 A Road Name: i2 i,. ' Zi
'p:
**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 Forrn/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
("•) ! /t '' L- �i/f�f '+ /U IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE % # BEDROOMS 3 # 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 W DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE F C t3 PUMP TANK % GAL. TRENCH WIDTH ���. / ROCK DEPTH A /d LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
i C
L i
{ 1
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30- 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
n ` r �� 1
SYSTEM INSTALLED BY:
AUTHORIZATION N0.5r-� 0 �j OPERATION PERMIT BY r ��r i.� i t �iJ�I J DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM D SCRIBED 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 02/02 (Revised)
,}'erriiitte`e's""' be 1`4
eDAVIE COUNTY HEALTH DEPARTMENT
Name: ✓ C n i I Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot.
AUTHORIZATION FOR
" WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 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 Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 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
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS _ J # BATHS # OCCUPANTS . GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
GOT SIZE C TYPE WATER SUPPLY (< ' DESIGN WASTEWATER FLOW (GPD) ( NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE X i 'OIL- PUMP TANK dGAL. TRENCH WIDTH � ROCK DEPTH ! )'? LINEAR FT.
OTHER ')l
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT
SYSTEM INSTALLED BY:
t kr
AUTHORIZATION NO. '' OPERATION PERMIT By.(i '-'rl 'i t ` 1 �:I i'
�' DATE:
*LATHE 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.
DCHD02/02(Revised) k_, ';f
/
II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT
SYSTEM INSTALLED BY:
t kr
AUTHORIZATION NO. '' OPERATION PERMIT By.(i '-'rl 'i t ` 1 �:I i'
�' DATE:
*LATHE 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.
DCHD02/02(Revised) k_, ';f
COMPLAINT FORM
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
Name of Complainant 39-12-b—nae h'dj&L
Address
Complaint
Person Responsible for Co
Address
Directions to Complaint
int
Date Received —'7-//-/o
Received By
Telephone
Telephone
Date Investigated :7 - Investigated By
Complaint Ju
Action Taken
Date Environmental Health Staff Signature
(DCHD 1/85)
GoMans GIS
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 7/12/2010