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AUTHORIZATION NO '�� � � � �,�bAVIE COUNTY HEALTH DEPARTMENT . ' �
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- Environmental Health Section. ` PROPERTY INFORMA ION
� - Pern�ittee's � _ - P O .Box 848 :�' � � ,
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Name: � *- ��- :� + . ,:;.r.. ocksville, NC�27028 : Subdivision Name: �
� ` � Phone # 336-751-$760 � �"�' ` �'
� '. '��"t" , ' Section: Lot: �"
Directions to property: � ��� � , .
\ �p � . AUTHORIZATION FOR � , � ;
' V �'M. ��> ��1.J l i 1`' �4� 1! �. r �u�i ; WASTEWATER Tax Office PIN:# _ _
SYSTFM CONSTRUCTION � . ' .
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�**NOT'E** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie,Counry Envuonmental I�1ch Secfion prior
to issuance`of,any Building��?ermits: This Form/AuthonzaUon Number should be presented to the Davie County Bu l�ng Inspechons �'
Office'when applying for Building Permits" , . = ,
(ln,com liance with Article l I,of G.S: Cha ter' 130A, Wastewater S stems �Section ,19O0 Sewa � G , ,
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p p y ge Treatment and Disposa! Sysms)
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`. f , /' 'y :• • ***NOTICE***..THIS AUTHORIZATION FOR WASTEWA'T� CONSTRUCTION `
\ ' ' ' ' � I � � � �L � � : IS VALm FOR A PERIOD OF FIVE YEAS. , `
'ENVIRONMENT. T}i-SPEC A�.I� DAT ISS ED �
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A DAVIE COUNTY H EALTH DEPARTMENT
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IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pe - ihee's �-
_�.. "I �' Subdivision Name: '}
Directions to property: ,,(j
Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# -
4" J � `P 41 Road Name: Zip;
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**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 pennit.
n (In compliance with Article I I of G.S, Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** TILS PERMIT IS SUBJECT TO REVOCATION IF SITE
1_s , PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMEN HE LTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE`
r . INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION. BUILDING TYPE }�1 # 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 C� DESIGN WASTEWATER FLOW (GPD) 3%D NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH !Z LINEAR FT. 00
OTHER 1 1S7Q 1!�uT�O� ►+,�SZAL(_ L O.C. #lA.,. .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
1 F19.T moPos- zn> k-,wc %:S NAY P&O -T, I- .s NST a&,\.
DCHD 05/96 (Revised)
DAVIE COUNTY HEALTH DEPARTN
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FO
(Check One) REPLACEMENT d REMODELING ❑
Name: S �'f_ DhG1ml f—bfAQ (— Phone Number:
Mailing Address: _31(D og �_gocl \ ic ,
fv\0C )ij e N(L Z7OZ$
Detailed Directions To
16
J � rvi S 'trt�i
(Work)
Property Address: 3_ � �o ; 922b"4 ( a 7� IM 1 VhOi1 MO C h5, U i j 1 C (,_) C 2-x) ?d,
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under 2Lt-040f 0 u',I d'• Type Of Dwelling:
Date System Installed(Mon ay/Year): Number Of Bedrooms: Z -Number Of People:
Is The Dwelling Currently Vacant? Yes No ❑ If Yes, For How Long? 47�
Any Known Problems? Yes ❑ No R'*'- If Yes, Explain:
�XC��c�,� � wc��e�^ �Soi'if'i r�•� l
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling:, 31,10 9 e W P 4 Number Of Bedrooms: 15 Number Of People:
7
Requested By:.
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
I (L
NOW
Requested: /,I —,;W 2tD"l
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:
Paid By: Received By:
Account #: D -<D C1 1 Invoice #: 22
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�9 a DAVIE COUNTY HEALTH DEPARTMENT
environmental Health'Section
PO Box 848/210 Hospital Street
Mocks rille, NC 27,028
' Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT' REMODELING ❑ RECONNECTION o
Name: S � C Phone Number: (Home)
-Mailing Address: •' L o a c i b c, (Work)
Detailed Directions To Site: Z�: uj r' J�_ n J ryi S 1); 4-
►`�1 a r Vie -I- a v2d tn.12 ,-N
Property Address:" PH�A(' t M l t\j')k-t k MOO C 7C) 7 �
Piease Fill In The Following Information About The Existing Dwelling.
Name System installed Under-- 4"W 0'WnCr Type Of -Dwelling:'
Date System Installed(Mon ay/Year): -Number Of Bedrooms: Number Of People
Is The Dwelling Currently Vacant? Yes No ❑ If Yes; For How Long? a�v7
Any Kno } ` Problems? Yes ❑ No V If Yes,'+Explain
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: o � G Number Of Bedrooms: Number Of People:
Requested By: Date Requested:
ignature) •
For Environmental Health Office Use Only
-Approved ❑ Disapproved ❑
�1 1
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 yvill function properly for any given period of time.
n
Payment: Cash ❑ Check ❑ Money Order ❑ # 1- — Amount: $ ji Date;
Paid By: I Rece ved Bv,�
Account #: �Invoice #:_-1-60 %,
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'� •, DAVIE COUNTY HEALTH DEPARTMENT
(Septic .Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S..Chapter 130 -Article 13C)
OWNER OR CONTRACTOR —_'I-ck m e _ ��� DATE �2 — 2 — 7 �o PERMIT 1 p
LOCATION of , 717t,4i \i3O. K'. 11a�,,e P%rcP nc�o�" M lU84
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME p' BUSINESS ❑
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE „-� YES ❑ NO ❑
SIZE OF TANK i==:..: '� `3'+` gal. 7
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY -
House Trailer 800 Gal.
Two Bedroom House 800 Gal.
Three Bedroom House 900 Gal.
Four Bedroom House 1000 Gal.
INSTALLED BY
400
Sq.
Ft.
600
Sq.
Ft.
900
Sq.
Ft.
1200
Sq.
Ft.
CERTIFICATE OF GOHPLETION By �, ;'t Date r r�tJ
(8/16/73) *Construction must c6mpVi'witl a`I1 other applicable State and local regulations
LOT AREA
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