259 Fulton RdPerm:ttee's' 1..� C ; c` A_ VIE COUNTY HEALTH DEPARTMENT
Name: ``-- �,c.c1 `'''�� "' Environmental Health Section PROPERTY INFORMATION
j_r� 7lti Ov i P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
(L 1 r�� •�t�`� Phone #: 336-751-8760
/ n ` Section:
AUTHORIZATION FOR
/ 0171' 0111 f` WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION ,r
AUTHORIZATION NO. 2. 0 9 6A Road Name
Lot:
f ` Zip: 2i c -u( ,
**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 Forn-/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.
ENVIRONMENuAL,'HEA-&H SPECIALIST} DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS —�L– # BATHS —4 # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
r,,� /�t ,�,
LOT SIZE `"TYPE WATER SUPPLY t-�flrf DESIGN WASTEWATER FLOW (GPD) "�� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH 19L LINEAR FT.
OTHER ' 7 ): a S
1
REQUIRED SITE MODIFICATIONS/CONDITIONS:1�:7 C�F'T �U[�� �`I �JA�`r� �+✓�r 00'3'1 CQi
IMPROVEMENT PERMIT LAYOUT o ccol,
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"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
Nc.-I�J v��l�—CAr•11L
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-TA►3k 't -ATC, y -q
SYSTEM INSTALLED BY:
Z
Num=
AUTHORIZATION NO.1124 OPERATION PERMIT BY:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIB A O&BUT
LLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTNO WAY BE TAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02102 (Revised)
10nl 13:00
DAVIE COUNTY HEALTH DEPARTMENT
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 ❑ RECONNECTION ❑
Detailed Directions To Site: t- UJ Tb ,_ , rC4 l Q
I S*- VbcA Al_"(Zv, k e--%-+ o n FW+0 n "
Property Address:a S_ 9 �)w 'b 0 "
Number: 33 (b 9� '4 Q (P (Q � 0 (Home)
c
l� 0 sC�:eZ (Work)
R
10+ on
Please Fill In The Following Information About The Existing Dwelling. 4 40=
Name System Installed Under: Type Of Dwelling:
9 PS ►
Date System Installed(Month/Day/Year): NOV Number Of Bedrooms: % Number Of People:_
Is The Dwelling Currently Vacant? _ Yes ❑ No�C If Yes, For How Long?
Any Known Problems? Yes ❑ Noy If Yes, Explain:
Please Fill In The Following Information About The New Dwelling-
Type
welling
Type Of Dwelling: Y CS i CisL cam- Number Of Bedrooms: Number Of People:
C_'k_t5e-
Requested By:
(Signature)
For Environmental Health Office Use Only
Approved ❑ Dis7-dM
proved F10d0 14
Comments: 0 K506), to) -7A_) -Z_
Environmental Health
Requested: V- /1 -U 2
k, 1-2 Az
*The signing of this form by the Environmental Hearth Staff is in no bay-Yntended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
00
Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ -1570Date:
Paid By: Received By:
Account #: Invoice #: _
Yl 2
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section P e-4 a -d S ; �e"
PO Box 848/210,Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Detailed Directions To Site: O W n ��w
~ trr),- r4 -k7-t 2, � n.4 }. o I-) 1 t ((iU Yl 1'2-,i
Number: E3 (n9 q D C0(D 0 (Home)
�q L' (Work)
jt,r2,. i i 1-44 ,n A�c,_-,Lj ?c -_)l
Property Address: Gl C% C C
x:
CNamePlease Fill In The Following Information About The Existing Dwelling: i1 40-
Name
Sysfem Installed Under: Type Of Dwelling: PS
f Gti� IG
Date System Installed(Month/Day/Year): / 9 Z/o Number Of Bedrooms: \ Number Of People:—
Is
eople:Is The Dwelling Currently Vacant? Yes ❑ No/9_' If Yes, For How Long?
Any Known Problems? Yes ❑ No�, If Yes, Explain:
Please Fill In The Following Information About The New.Dwelling:
Type Of Dwelling: P S ci c.<_._ Number Of Bedrooms: 3) Number Of People:
Requested By:
L'`_. ( ` (__ , \-svu-
(Signature)
Requested: 9- 19-L9
2
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments: �t`#' !1 l t`. j ��t1 e)t (U 1-7 jo S
i
Environmental Health Specialist % - r ; `Date
*The signing of this form by the Environmental Hea7th,Staff is,in•no *ay -intended, nor should be taken as a
guarantee(extended or limited) that the on-sitewas`tewater system will function properly for any given period of time.
00
Payment: Cash ❑ Check ❑ Money Order q' # Amount: $ => Date:
Paid By: t""f "Recei�iedBy _ -_
4 i �,
Account #: '� `; ,, ._w _ . .,.:..Invoice #:
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4 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section D
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760 104-0
ON-SITE WASTEWATER CERTIFICATION FOR D LIN 11002
(Check One) REPLACEMENT ❑ REMODELING ❑ RECO
(� G� _ y�cO�N y�ni
Name: ,C_�2,-� U 0 n ��'` Phone Number: f D i (Home)
Mailing Address:
Detailed Directions To Site: G 4-o O e- i--' U'C-
�..�+ '4- i yz- 2 5,-, o A" A -7 -
Property Address:
Please Fill Fill In The Following Information About The Existing Dwelling:
Name System Installed Under:.
Type Of Dwelling:
Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People:
Is The Dwelling Currently Vacant? Yes ❑ No ❑
If Yes, For How Long?.
Any Known Problems? Yes ❑ No ❑ If Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
1 iaa/v_rt- za'/?)0_4�
Type Of Dwelling: Number Of Bedrooms: Number Of People:
Requested By: Date Requested: 3- Z --
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments:
Environmental Health Specialist Date
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By: q Received By:
Account #: L S Invoice #:
4fe
DAVIE COUNTY HEALTH DEPARTMENT
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 ❑ RECO,*NNECTIO'N/ ❑
I \
Name: C a R I/ d i n e ' Phone Number: ! �� `� 7 �" (Home)
i
Mailing Address:TZS 6:�,,_(Work)
()Q
Detailed Directions To Site: L< <i is 4, rG' 1C
Property Address:�—
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under:
Type Of Dwelling:
Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People:
Is The Dwelling Currently Vacant?J Yes ❑ No ❑ If Yes, For How Long?
9 ,, r -
Any Known Problems? Yes ❑ No ❑ If Yes, Explain:
Please Fill Iri Th"e Following Information About The New Dwelling:
Type Of Dwelling: Number Of Bedrooms: Number Of People:
Requested B
Date Requested: •'�''` � h �'�----.
(Signature) 1
For Environmental Health Office Use Only
Approved 0 Disapproved Ei j
Cnmmenft-
i
Environmental Health Specialist - Date
'"The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By: Received By:
Account #: ,` =-' Invoice #:
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes *No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: �} dlfzela� WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: #�� �%7 4� &2,.( ��,CGS/� %d - �X�7
Property Address: Road Name �� ��/�f/lr' �� / 5-1-le,i T,
City/Zip //Gig /�' ds O/7
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing
—>procedures as necessary to determine the site suits ' 'ty.
DATE �"-, ✓ 0 aZ. SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No.
Revised DCHD (07/99) Invoice No.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &
11r1
rg
Davie County Health Department
L� -`'!
Environments/Hes/th Section
P.O. Box 848/210 Hospital Street
DEC 3 C
Mocksville, NC 27028
(336) 751-8760._��
ENV1R0� %,';P,17A! HE-A�7H
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS
PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
Name to be Billed
r
//Q� �►� Contact Person
Mailing Address(/
_
1 //
/�J Home Phone
City/State/ZIP/�,q
e Q� ��(� • �_ ((%��O Business Phone
2.
Name on Permit/ATC
if Different than Above
Mailing Address
City/State/Zip
3.
Application For:
❑ Site Evaluation IX Improvement Permit/ATC ❑ Both
4.
System to Service:
House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5.
If Residence:
# People # Bedrooms # Bathrooms
'Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6.
If Business/Industry/Other: Specify type # People # Sinks
# Commodes
# Showers # Urinals # Water Coolers
IF FOODSERVICE:
# Seats Estimated Water Usage (gallons per day)
7.
Type of water supply: X County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes *No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: �} dlfzela� WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: #�� �%7 4� &2,.( ��,CGS/� %d - �X�7
Property Address: Road Name �� ��/�f/lr' �� / 5-1-le,i T,
City/Zip //Gig /�' ds O/7
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing
—>procedures as necessary to determine the site suits ' 'ty.
DATE �"-, ✓ 0 aZ. SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No.
Revised DCHD (07/99) Invoice No.
22 - yV C tS���