189 James Rd (2) W R - � -r.:i n ��.-, i y,:.-- { r,•., ° ar {"=tt Sl'''y •r ► +-c�' +vri+' �,rt': � ya;,.�-p -..=r}r ti .t,'t-a:tat J�'yi`l�'+== ;J�} '" fd�' '.Ri li�i
AUTHORIZ TION NO j A H DAVIE COUNTY HEALTDEPARTMENT
.` �
Environmental Health Section PROPERTY INFORMATION
Permittee'~ P.O.Box 848
Name: CMocksville,`NC 27028 Subdivision Name:
property: t='t t7 F Phone# 336-751-8760
Directions to ��L Section: Lot:
AUTHORIZATION FOR
t , ��y WASTEWATER
�11X � �Q' V LS ``' SYSTEM CONSTRUCTION Tax Office PIN:# - -
{�"i 15 q
'007 �,q M1LE 01J 1.1+FT���� ,� #!�i Road Nan.-.Q!! !00k-5 �� zlp; Z 7a �u
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance.of any BuildingPemuts:This Form/Authorization Number should be presented to the Davie County Building Inspections j
Office when applying forBuilding Permits.
(In compliance with Article I of G.S.Chapter 130A,"Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTI01 "
+r :� ✓ �� Tf IS VALID FOR A PERIOD OF FIVE YEARS.
,{&AbN AL hi A Lf H 2B JALIST D TE I SUED
►' ' A DAVIE COUNTY HEALTH DEPARTMENT /- I .�
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
r
Permittee's ,
Name:. fh.- w: ?.# t: - Subdivision'1Vame:
Directions to property: (i J.t� -t,. I i al / Section: Lot:
-
r - J IMPROVEMENT
1 . 1 1_. k,, l
PERMIT Tax Office PIN:#
"I {` ` �"*Ls � MILL t"r � cf e tY 4
Road p.'t.
�., ad Name. Zi
*,*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,l 1 of G.S.Chapter 130A,Wastewater.Systems,Section.1900 Sewage Treatment and Disposal Systems)
j
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
�. �—ENVIRONMENTAL HEALTH SPECIALIST D TE I SUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
{{ ,• INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE rn 14 .#BEDROOMS Z #BATHS �- #OCCUPANTS 2 GARBAGE DISPOSAL:Yes o No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes
LOT SIZE �%-D� TYPE WATER SUPPI, ' Oj4jj DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE 1
SYSTEM SPECIFICATIONS: TANK SIZE '` C:" GAL. PUMP TANKGAL. TRENCH WIDTH +��r, ROCK DEPTH � " LINEAR FT. 2
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: F x 4 to O`F' i 2Jf (�1 nJ 1�-_ , 1=►" 1 [:R Y- 4 Uwh���
TWO WA %-tz it cam; S
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER* 4RISER(S) IF 6" BELOW FINISHED GRADE*
(' D I
Z-
0 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((1 ,r9%6x
'(336)751-8761
OPERATION PERMIT
SYSTEM INSTALLED BY. �^E�Mp� 14;
J�
���� ty\•'>i l�ln/L�i � �� I tJ �t�i (�Cl�c�D�
AUTHORIZATION NO. �1p 1��` OPERATION PERMIT B DATE: Q
"`*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT STEM DESCRIBED A 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)
J
,.-.'R,y;.i`a+i`--' `� � .`.F-b.Y'1v.sr 1.^y"•-' .a.''S G Y 1 .t..= "o•" v f ` � �,��, •�',\
DAVIE COUNTY HEALTH DEPARTMENT /7Y
='
w ,, I , �
^� :.. IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's •; '
Name: '` Subdivision'Name:
Directions to property: P' >" 'I*{ Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
,,>? Mit(. - i i - Road Name:1 Zip: _. t
*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/mstallation 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)
r- ^`'"" r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DTE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE N #BEDROOMS #BATHS M #OCCUPANTS L GARBAGE DISPOSAL:Yes oNo) Y
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes q
{
LOT SIZE TYPE WATER SUPPLY l { t)rat DESIGN WASTEWATER FLOW(GPD) 'A' NEW SITE REPAIR SITE ✓�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ^- ROCK DEPTH I "1 LINEAR FT. ./ t
OTHER + i`=."� ti.,1 l rT l
REQUIRED SITE MODIFICATIONS/CONDITIONS: r+tLf�)p{) 1-�(Lt � �� '{i 'y' t• ?eni [( i(�k: i�yJ�J( ���Ct_4 1�, l�i,.A .€��
i;:...A)o Y�II R.�. 4, l._�N� L..L.M.7�-' j`4•-41 ar'n..�'T Lr� `�- �.�t� ..-.�.y.',,if t I-`.�i.'
IMPROVEMENT PERMIT LAYOUT 01PPROVED EFFLUi;WT FILTER* *RISER(S) IF b'+' BELOW FItdISl4ED GRADE*
�a
,�..
,,.
� G
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTI
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE
OPERATION PERMIT
SYSTEM INSTALLED
4
AUTHORIZATION NO. �' OPERATION PERMIT B/: ( .Gv'i
DATE: laq
u
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THATS STEM DESCRIBED A 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)
x
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PATRICIA MILLER
Z
N .----_ EIP (PIP TO PIP) ( C/L
�'i N 86'28'311 330.00'TOTAL—+ PI PAVED
vgPI EIP
0.22' 329.78' POWER •
(PIP TO EIP) ,-!, POLE
DISTURB
P
0.998 AC t/)
N RE 65.61 U
,,. .4'
BY COORDINATES SONE
_ 1
I�.3 �4
PIAT BOOK 5 PAGE 99
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TAX MAP N0. H-7-3 I.I+ PIP —'
DAVID SPACH AND WIFE, �pppg '
0•µ• I 326.26
SUSIE R. SPACH (PIP TO OLD 1 (OLD ANGLE IRON �1 MER
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DB 98 PG 487 ANGLE IRON) I TO PIP) ` -� U`
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\ TN ARCEL 3,2S
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TAX MAP NO. H-7-3 I p0 164 PG 919 .r
CA9, SU
RVEY
'60 0 I .-*of ���% GORADY I. TUTTEROW CERTIFY THAT UNOER Pi
60 19n �_:Ap ESSQn,. -- RECTION ANTI 1;1,Pr..,.. .
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑
Name: a"ew_ Phone Number: �Y 3SS� (Home)
Mailing Address: �- '-2-2 (Work)
Detailed Directions To Site://4v[/ e!5,7 6/* �/7 kf'—Agal "72;-,'W
�• O�
5 5r,;,wer /ems. O�7 •C. o�i�� % �7:/ —
4 o
Property Address:
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: Z: ,44 ell Type Of Dwelling:
Date System Installed(Month/Day/Year): Number Of Bedrooms:_,! Number Of People: 2
Is The Dwelling Currently Vacant? Yes�m/No❑ If Yes,For How Long?
Any Known Problems?Yes❑ No R If Yes,Explain: ^—
Please Fill In The Following Information About The New Dwelling:
Type Of Dwellin �� /e6/,'���/ Number Of Bedrooms: � Number Of People:
Requested By:� �Q�t lJe-��c- ,Cl,� Date Requested 7 ^ Z 3 -R/F
(Signature)
For Environmental Health Office Use Only
Approved ❑nn Disapproved Q'-
Comments: A&e- or -I- Abhc5b ��ww,,. -- E�E- f-leDeD ac3 Q-0QA%P-
S�ls-r�-ri....
Environmental Health Specialis Date R
*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 #: (OlO Invoice #: O ��