3137 Hwy 64EPermittee s% DAME COUNTY HEALTH DEPARTMENT
A Name, 0,V * ik, i %fir.% ,�'X�,15 Environmental Health Section PROPERTY INFORMATION
,l !' P.O. Box 848
_ Directions to property: t `r� Yf�'Cr Mocksville NC 27028 Subdivision Name:
fr/1 , lff �/r n r ���/r7cG fJ.rire Phone #: 336-751-8760
Section:_
,1 AUTHORIZATION FOR
V •s' �Y f A v / lr WASTEWATER
Lot:
Z.r.- 4,Tax Office PIN:# - -
SYSTEM CONSTRUCTION_
f6 �,yl C Y � 3 7 t t�. • C L
AUTHORIZATION NO: 002746 A Atr(ss fiL Road Name: C`
**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 1 I of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
f
�,. _ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 2 ` i G � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS �o GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE '# PEOPLE # PEOPLE/SHIFT / 1 ' # SEATS /+ INDUSTRIAL WASTE: Yes o4
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE 'REPAIR SITE
idI
SYSTEM SPECIFICATIONS: TANK SIZE f K"GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER '1;AIgC, tv LXA t 5't <<'t` �',A{cr—lp C�C_ t55 IrtS�cR�r'rOn
jtn5jr 1 lu �1aw c ak h -r Tc k r c L k—cl . C
REQUIRED SITE MODIFICATIONS/CONDITIONS: C o ►A npt
IMPROVEMENT PERMIT LAYOUT
I
50 >r
p n Z N .P a� k .P d �j i � .� D-1 f k-•-- � \
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT �''
SYSTEM INSTALLED BY: Rom- nOrX ��11 II C G UZ
41w (P
u ( 3'` p -JL S t-1, � u
ad�� AJC Gr." 4o
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-T Pe -ICA
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: ' 1 I O%
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA 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 GIVENPERIOD OF TIME.
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DCHD 02102 (Revised) D //Zx
DA IE COUNTY HEALTH DEPARTMENT Z11002
Environmental Health Section PROPERTY71 FORMATION
Fa.-i/Lrtr�li� P.O. Box 848
DlrecTbons to. property: yMocksville, NC 27028 Subdivision Name:
'� Phone #: 336-751-8760
j/
Section: Lot:
` . AUTHORIZATION FOR
f�(/! �j 7 '` td'r ✓J / G rl�� [. , ; ei'' WASTEWATER - -
SYSTEM CONSTRUCTIOIN Tax Office PIN:#
AUTHORIZATION NO: W2746 A jbIK Road Name: Zip: )ie -G G_
**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 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
w _
' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
—e' f IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE 'U� /# PEOPLE )" # PEOPLE/SHIFT / 1 3 # SEATS INDUSTRIAL WASTE: Yes or®
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE f k' -'GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. -
OTHER -j1k5'f'U`(�yv [Mt.IS� �ut1 :C�^J�wt�cr f�c����ti�� (i1Sw_l�1Un
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REQUIRED SITE MODIFICATIONS/CONDITIONS: Ir k 41t.
Q F U 13 j
IMPROVEMENT PERMIT LAYOUT 1,
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416 -
FOR
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT `,� 1 I
SYSTEM INSTALLED BY: Me- \\p " \CA ' 1U n (�Tt L V i Com-
1 �
,:5y Ckcu_ i / 'E m S.T. 4-L, C1 ICU
v or
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: Z11 Imo%
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE'THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 02102 A -Sed)
0 Y % a7 '
Permitteej- - - DAVIE COUNTY HEALTH DEPARTMENT
2.?ame `(-I v k)`i uq Environmental Health Section PROPERTY INFORMATION
1=� G P.O. Box 848
Directions to property: tai' Mocksville, NC 27028 Subdivision Name:
t y� t f � G "t L C+ r. + t,• "a ti c'u.v� lrr., / ( �, Phone #: 336-751-8760
t Section: Lot:
�j AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
% ,
SYSTEM CONSTRUCTION 313-7 f , 4,) �
AUTHORIZATION NO: 002 7 4 5 tIF� V Lj to Road Name: F t: Zip: ' 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 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
✓' ' "� �`
/9
� 7( IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS
++ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE )+ # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes bx,cuv
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT Y. �j (u I It r ✓ti` 1-1S t C. a I -C
4 G h 2 X i �� i .t51 t A _ —�.J
5 cx v i, .n y a7' 75 rP I c
kip- by. rro(,f,r�.Ay ; / t Lld
l
Sck,Vdlut.o 4 ^ /
c
PVC— Pry t`
i
-�lww 'io ter ltw.u& �'-4 �}
Sho..td Luu-e
b o t tD w^ 114
R.f.0 cwt o1 1p«r�ihwige-=-'Sj
to allow flow ave outer 5rd•e
FOR FINAL INSPECTION F THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760..
OPERATION PERMIT
SYSTEM INSTALLED BY:
ke i ao C
z
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 I 1 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 GIVENPERIOD OF TIME.
nolo ozioz (Revised>
/r
c �
�C Y
S�SN •r
1 ✓ \,, r Us( C,
Pe ` DAVIE COUNTY HEALTH DEPARTMENT
i
v ' c
` 1 ' # ""'�" r 'I �� 1„y` �, Environmental Health Section PROPERTY INFORMATION
w P.O. Box 848
Directions to property: �(� I'- e'r l �' c ' Mocksville, NC 27028 Subdivision Name:
ff ,1 Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
-+' t, L• , � I �t t 1,<. WASTEWATER
Lot:
( i t c • e , , C. F +t., car, c "F Tax Office PIN:#
SYSTEM CONSTRUCTION I
IT
O0274 4 3
1 t, 11(_
AUTHORIZATION NO: A V� ' `'' r j, Road Name: Zip:
**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 Forrn/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.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE a. # PEOPLE/SHIFT
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) _
# OCCUPANTS GARBAGE DISPOSAL: Yes or No
# SEATS G INDUSTRIAL WASTE: Yes OiZ
NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
A 6 p vt e r i -� A 4' :t -, L I^
'1 e w k, O {n c( 1,c p el it
by rvucre y
.C. k. S►r ., � rot C wkIu14
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y �t SC6'rAL,t., ao
1.
I
1 :r'ccf i,•(
{ !1N
7 hc, k Av-C I, V �
bott-aw, 11y crf 4 r
C
FOR FINAL INSPECTION bF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
po(m
+
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 I I 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 02!02 (Revised)
Ir
FEB 2 2007
ENVIRONMENTALSITE
--...r....�..__DAVIE COUN"
Name: H a f 09—A
Mailing
VIE COUNTY HEA ,— L � 4f t
LTH DEPARTMENT
Environmental Health Section issued,
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ASTEWATER CERTIFICATION FOR DWELLING
X
❑ ' REMODELING ❑ RECONNECTION ❑
one Number: l✓ & )A j �
CiHome)
(Work)
Detailed Directions To Site: (4 cz) y b 1"C3 co,-
<A C k.1 -1 -y -c I-
-Property Address: ( 39 U5
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? 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:
�o-zv 9-G
l
Type Of Dwelling:.a � � mber Of Bedrooms: L Number Of People:
Requested
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved fT
Requested:. �– +✓_ �� ff`y_%
Environmental Health SpecialistX�,/,—/--Ae 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 #:
� . �' z a