P0906 Godbey Rd l�;Zs'uS•t w.,;i; �!'�, i°� t4'y g�...r __5:..,, 1i,Y`'7 1 x,� 4 a. ..'4;p, [ nr '=S;: a�; x - ,' s,t 'f,-.'., _.,.�-: i y]r;�t - r x.
A QR;ATION,NO. 0906:'- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health,Section PROPERTY INFORMATION
PermiftWs X* • P.O.Box 848
}Name :,r �. � . .� '" Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property: fX\ Section: Lot:
. ' ,, AUTHORIZATION FOR
IV
� � c�> WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION.
Road Name: * K6 Zip: A May
**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.130.A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
k� C� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� 't� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST.;, DATE ISSUED
+ .ry •F• •: fa, "'C 3'f�t n..':.;:� <2,'iT ""i��;M.. 7•R il Y"'..4/3'i y '+_y..'�1,�w"�a;i li rr --"5rh A.. _�`5" 4} t�'.f'vr Zr,Tw::f gf,:..y 'y._ r p -.
�• DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permltte 's t • ' _
Name �r ' `!� . � " Subdivision Name:
1 ,
Directions to property: � � :r Section: Lot:
_ IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name:(%!A \fit -, 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
IN
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 o m-Sk #BEDROOMS�_#BATHS_�#OCCUPANTS - GARBAGE DISPOSAL:Yes 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
)y` 5
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH f': LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
W Q U 5-Q
��W(1
'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 INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: 00NP,IC& LA
1b,
n
J
3 60
paw � (�YJ
AUTHORIZATION NO.-�OPERATION PERMIT BY: UM DATE: - 7� 8 /
**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) g'
a
' DAVIE COUNTY HEALTH DEPARTMENTXX) '
° ' - '
„'.
IMPROVEMENT AND.OPERATION PERMITS PROPERTY INFORMATION
1amc �t�► 4 Subdivision Name:
'Da tions to.property: � ``t SectionLot:
' �'�, .�'-•�N '°S k�L ` ' �V * rLRll� Tax^Offce ,.. e.
PINI
`s Road Name: 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
constluction/nikallation.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 Tmatmentand Disposal'Systems)
***NOTICE***THIS PERMIT LS SUBJECT TO REVOCATION IF SITE
• t° ., g�, ' ;• r ~•� 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 TYPEI�fto meq, #BEDROOMS _#BATHS_J_#OCCUPANTS
t- �_GARBAGE DISPOSAL:Yes No
COMMERCIAL SPECIFIc(hom FACILITY TYPE`- #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
•, y.. V /S
l
LOT SIZE OSS 'TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
g �
SYSTEM SPECIFICATIONS: TANK SIZE . GAL PUMP TANK GAL. TRENCH,WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONSICONDTtIONSc ' r
IMPROVEMENT PERMIT.L'AYOUT '
O U .3q f{
- _
ILO.
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY_HEALTH DEPARTMENTTOR 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)6348760. "
OPERATION PERMIT DNa` `
SYSTEM INSTALLED BY: t1 6 j:�,14fq
0
' �Io�ISt
3 too
T
AUTHORIZATION NO. OPERATION PERMIT BY: LG(.f 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME
DCHD 05//(/�,�//pper�
. I
.. LAto vo �
9�3� -
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME U 46u h �("ewRI.e PHONE NUMBER—OU-7Z,3
ADDRESSC-X)ELC Y V17 2 S3 V M,i-`o.S%DIVISION NAME
LOT #
ey L43101— 3?
IRECTIONS TO SIT �`l� v Of� =F-� - �y W - c� Co
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER 404' R ��CAStL
TYPE FACILITY RQ0S NUMBER BEDROOMS NUMBER PEOPLE SERVED Z
TYPE WATER SUPPLYn SPECIFY PROBLEM OCCURRING L1,�ES 5'[t�IGJ7
DATE REQUESTED INFORMATION TAKEN BY
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
t V-� oo04. , Pkrtt,