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AUTHORIZATION NO: 05 16'. DAVIE.COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's / P.OBox 848.
Name: -. 1 / Mocksville,NC 27028 Subdivision Name:
. — t phone#:704-634-8760
Directions to property: ���E? �f,�!//t��:�l/d+� ! Section: Lot:'
AUTHORIZATION FOR
nQAk C0.A C*':1! WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
(tee, O�c�.SCC 0 O I `"_' tel.
�'h� Road Name: r'YY11 iP:ia_70 017,
**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 Pen-nits.
(In compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
10
' t, �I' IS VALID FOR PERIOD OF FIVE YEARS. ,
ENVIRONMENTAL HE ALT SPE .:• .DATE ISSUED .
7"T:`"i'i
DAVIE.COUNTY HEALTH DEPARTMENT
} `" IMPROVEMENT AND OPERATION PERMITS ' PROPERTY INFORMATION
n Petmi40-exs=aa,
Nam2
e: .o` C`, Subdivision Name:
Directig.As to property:'�' � ` r� t E Section: Lot:
IMPROVEMENT
Q0A Q*,j• PERMIT Tax Office PIN:#
=40,SS41,Z . � P—C-- Fox-ryN%" � P �g
**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
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEAL SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS�S� #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPEEf #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ( tS DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH,- _L__ LINEAR Fr.
OTHER (2?
REQUIRED SITE MODIFICATIONS/CONDITIONS: ?
IMPROVEMENT PERMIT LAYOUT 1�{
**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)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
K
7 .
k"
- J
AUTHORIZATION NO. OPERATION PERMIT BY: L e 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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
.+Y .C .^w;,4,.t;t+ f f tir, f +d ;s.-' ..1'.q.:s. ,.-•=y'f•�,. Y.r"y... ..t -�s.,r _ y ..
DAVIE COUNTY HEALTH DEPARTMENT
....-'` . " IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permitted's " :-
a� 1 rr +,
Name: /�r'o a `�j Subdivision Name:
Directions to property:.,/' ,�'�� � � r``cam Section: Lot:
IMPROVEMENT`
e.a-1 C 1 • PERMIT Tax Office PIN1 - -
Id 50 1-t 0 0! + p:��'' r
0 11 Y"' : Road Name: a��In I 2LZic $
**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
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTk SPECIALIST "DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS,,? #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPEE�, #PEOPLE - #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY r U DESIGN WASTEWATER FLOW(GPD) -,?X NEW SITE REPAIR SITE
•.SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH.,4{� LINEAR Fr. 00
OTHER 4:�2 1F� �"
REQUIRED SITE MODIFICATIONS/CONDITIONS: I Y
IMPROVEMENT PERMIT LAYOUT
(
i
"CONTACT A REPRESENTATIVE OF THE DAME 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)6348760.
OPERATION PERMIT '
SYSTEM INSTALLED BY:
t
t.
rF
r
AUTHORIZATION NO. OPERATION PERMIT BY: 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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
r
DCHD 05/96(Revised)
e �,�✓ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ��li'l9ni"( PHONE NUMBER
ADDRESS 716 /CAiC' SUBDIVISION NAME 'Z7�
✓hdLv%llC. ,/�G 270 ? .e
� LOT#
DIRECTIONS TO SITE Ael- V2
DATE SYSTEM INSTALLED 94,01 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY //00-r- NUMBER BEDROOMS NUMBER PEOPLE SERVED -3
TYPE WATER SUPPLY C 6j SPECIFY PROBLEM OCCURRING_ 40LA&L w/ ltu4
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I under nd I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93