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1653 Jericho Church RdF ,PerLtfee's'; ' �� ( DAVIE COUNTY HEALTH DEPARTMENT Name: i (' Environmental Health Section P.O. Box 848 jqp�-le w PROPERTY INFORMATION Directions toproperty: f '' Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 �... r� AUTHORIZATION FOR ,. 1 3 oc�� C Z I( t 1 (i, j C f t^ WASTEWATER I SYSTEM CONSTRUCTION AUTHORIZATION NO: 0039-20 A Section: Lot: Tax Office PIN:# Road Name: **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 .1900 Sewage Treatment and Disposal Systems) I �, �: f 1• ***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 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE ( # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY &A tt( DESIGN WASTEWATER FLOW (GPD) D NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE CGAL. PUMP TANK GAL. TRENCH WIDTH �YL— ROCK DEPTH LINEAR FT. / O REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT fi al v�- �`' a i l)rr �%�' ��� •' � J\ t0 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. I OPERATION PERMIT SYSTEM INSTALLED BY: A in Pon AUTHORIZATION NO.� OPERATION PERMIT BY: DATE: C/ **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO dHAS 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 02/02 (Revised)�� ` -� 1 �1 A in Pon AUTHORIZATION NO.� OPERATION PERMIT BY: DATE: C/ **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO dHAS 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 02/02 (Revised)�� ` -� >Id w.Eerriiitee's '. j DAVIE COUNTY HEALTH DEPARTMENT Name: - l f '` �- Environmental -Health Section PROPERTY INFORMATION P.O. Box 848 Directions to roperty: ' Mocksville NC 27028 Subdivision Name: 1, — • ,.. { Phone #: 336-751-8760 Section: Lot: f r AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO: 00020 A Road Name. ih( rip: f f **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 Fonn/Authorization Number should be presented to the bavie County Building Inspections Office when applying for Building Pen -nits. (In compliance with Article I 1 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 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY C�'G'DESIGN WASTEWATER FLOW (GPD) -7(- n NEW SITE REPAIR SITE i . SYSTEM SPECIFICATIONS: TANK SIZE F'�GAL. PUMP TANK GAL. TRENCH. WIDTHROCK DEPTH LINEAR FT. y OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 1� I 11 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. 1 OPERATION PERMIT ' SYSTEM INSTALLED BY: 12-o.nda I I >•c 1 C -- LA �' AUTHORIZATION NO. �.640 OPERATION PERMIT BY: �j .i DATE: 5 ,g© *'"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO 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 07102 (Revised) I i;^ � T - : r. 7 _ r 1 �: �1! --' - /.:— 4� )seniii-ttee s (` .DAVIE COUNTY HEALTH DEPARTMENT Name: ✓ ' ! . �',� ale .' Environmental Health Section P.O. Box 848 PROPERTY INFORMATION Directions to property: I(.� --" , , I: •'.ter; Mocksville, NC 27028 Subdivision Name: K• ;, .!% Phone #: 336-751-8760 t ,% Section: •AUTHORIZATION FOR { _ WASTEWATER Tax Office SYSTEM CONSTRUCTION rh AUTHORIZATION NO: ARoad Name: Lot: **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 G' - ✓' ` {° ` ,., �� / ,�` ✓f IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST 'PDATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE // # BEDROOMS # BATHS 0-0 OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE LOT SIZE TYPE WATER SUPPLY e"� # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No DESIGN WASTEWATER FLOW (GPD) �, tZ 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 AV -1t -- "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 (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 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. DCHD 02/02 (Revised) '331nti�ttee's `y+ ' ' 'DAVIE COUNTY HEALTH DEPARTMENT t / " 'Name:'' A Environmental Health Section PROPERTY INFORMATION .� P.O. Box 848 ;.Directions to property 3 f Mocksville, NC 27028 Subdivision Name: .� Phone #: 336-751-8760 F` Section: L'ot AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION P -- AUTHORIZATION NO: 1 " ` A Rd Nam ri�' io � h �a *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 l l 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 OL— # 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 tr' SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT f ' A 40 j� "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 (336)751-8760. i OPERATION PERMIT F SYSTEM INSTALLED BY: s r i (C „ I AUTHORIZATION NO. OPERATION PERMIT BY: 1 DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDIIPATE 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 qF TIME.E' DCHD 02/02 (Revised) A TH . IZ MAJ,12 N NO DAME COUNTY HEAL • p %� Op, TH DEPARTMENT33� h (C��, Environmental Health Section PROPERTY INFORMATION Pe'rmittee's% '�%t•�Jl:t7�%�i%% P.O. Box 848 Name: /—L` 1J/it %h"j •' Mocksville, NC 27028 Subdivision Name: Ill"'Phone # 336-751-8760 Directions to property: V /`�r ' ��'tr,✓i Section: AUTHORIZATION FOR ` WASTEWATER Lot: ' SYSTEM CONSTRUCTION ��x .Office PAIN:# / - Road Name: 1 ;; :'f,Zip: 7 3. **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 .1900 Sewage Treatment and Disposal Systems) f f , ,. ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION r�fENVIRONMENTAL ��� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL ENVIRONMENTAL HEALTH DATE ISSUED R, DAVIE COUNTY HEALTH DEPARTMENT R ., �r � �' ��/; .-.1. IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION •Permittee s, •% ' / Name: ' -J ' Subdivision Name: _Directions to property: \(I L a Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# - Road Name: , , y 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** TI -IIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE Z-1 # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TY,P�E+ # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ( e) DESIGN WASTEWATER FLOW (GPD) - tl NEW SITE REPAIR, SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH�� LINEAR FT.o 6),/) OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER* *RISER (S) IF S" EEL0 FIt1IG?;EB "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}634-8f6Ei. • liM1tH3LXXM3C OPERATION PERMIT SYSTEM INSTALLED BY: r,. AUTHORIZATION NO. 11'.10A OPERATION PERMIT BY: DATE: *'"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 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. I i !/v wuv v✓�wk CVv , 'te / I J �"�1.�*�►'"� ' r �' µ�". . P... _ - "�r.r•� irk _iI-�.��,� �\�; 1 DAVIE COUNTY'HEALTH DEPARTMENT �, IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee s N�Ine:" Subdivision Name: _Directions to property: ` ` Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# - - P' ij Road Name: Zit): **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 constructionrnstallation 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 HEALTH 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 TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY C6, DESIGN WASTEWATER FLOW (GPD) JFh" NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH X• LINEAR +. .. • ATiSCD REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT -:zAPPROVED EFFLIJ YET FILTEP* *RI ER(S) IF 5"' 11E OT" FIN"AISFIE-D Gilf=F* t 1 ( � r "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 5704} 634-836P )C),);3 xY,).XX OPERATION PERMIT SYSTEM INSTALLED BY: 1 AUTHORIZATION NO. OPERATION PERMIT BY: Lti'(.� DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THATTHE 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 (Revisidf ~ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME Xi PHONE NUMBER ADDRESS A?�7 '6'U��%l �C-�/�e SUBDIVISION NAME AlGc4s4,�rlle LOT # DIRECTIONS TO SITE / �� �� �"01C___4 , , ems, 4'e X0 CX" 2�1.' DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY #OWS C_ NUMBER BEDROOMS 9 NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �/G 00 z DATE REQUESTED 3 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 Rev. 1/93