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AUTHORIZATION NO DAVIE COUNTY HEALTH DEPARTMENT'
Environmental,Health Section PROPERTY INFORMATION
P'rmittee's P.O.Box 848
"Name: Mocksville,NC 27.028 Subdivision Name:
Phone#'336 751=8760
Directions to property, , Section: Lot:-
AUTHORIZATION FOR
WASTEWATER , Tax Office PIN:# - -
SYSTEM CONSTRUCTION
{ Road Name: a/�� Zip: Z7
*NOTE**This'Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Buildin'gPermits.'This Form/Authorization Number should bepresent ed to the Davie Counry;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)
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T
--*NO ICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTHPkIALIST DATE ISSUED
r'..-+ • 9 qT O ,�.,,.v.... f ...-...vt. ':s vsr + ,; . a i..r'-,..4`9_rf i,a i __ _
r '+ DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION, r.
. .Permittee's'
Name: ` ' , ! „< Subdivision Name:
`Directions to property: �' � l r' Section: Lot:
1. IMPROVEMENT
PERMIT Tax Office PINS:#
Road Name: Zip: 27yp_
**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)
✓ `� f ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
,. �'.. '' �,;• ,1� . } f' , G' PLANS OR THE INTENDED USE CHANGE.YOUR WASTE......R
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFOREF r
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE _ #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 DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
'�s�►-�`
SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHROCK DEPTH O?V LINEAR FT. '
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*APPROVED EFFLUENT FILTER* *RISER(S) IF 69' BELOW FINISHED GRADE*
**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. '
xxxxxxxxx
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. , /i OPERATION PERMIT BY: DATE:
j **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)
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"40 'I ,' i.8 U/i DAVIE COUNTY HEALTH DEPARTMENT /
ArI' .
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORM ION
r"~Permtttee's '
Name: '"! * / je '�'s f Subdivision Name:
f :4 Directions to property: ` Section: Lot:
IMPROVEMENT x
PERMIT Tax Office PIN:#
Road Name:(F'� 1 6 4 ...1.141 z, ' Z.
p:. �
**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) a
r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
/t. 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_� #BEDROOMS #BATHS—7/—#OCCUPANTS GARBAGE DISPOSAL Yes o;.No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE.Yes i No `
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)' NEW SITE REPAIR SITE
.F
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH C^ ROCK DEPTH PFL,LINEAR FT. d `
/
OTHER '
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
pFRI�4tED EFFLUENT FIL7ER�' *RISER(S) IF 6" BELOW FINIGHED GRAb��:
t'
je
i .
t-
` "*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.
XXXXXXXXX .�
OPERATION PERMIT '.
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. ` O/r OPERATION PERMIT BY: *' DATE:V'
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*"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
t GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
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s �1� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME Y 'Zl4 PHONE NUMBER
ADDRESS �� ry f SUBDIVISION NAME
(/ r En fq
SU IVISION LOT# �.
DIRECTIONS TO SITE r �'
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o �n
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED ���;/�o INFORMATION TAKEN BY