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111 Ken Hoots ln �5��,»-> dri..� � '{�«.Y}�:'t '?+saro . .., .. , ; . :. ,.; .; - - � - ... .. _ u i :.li . '�t� �e�r'+-te ,''t+±��X e�'��.�`�.-"�.+ - i+,�.i�`'�t .1."''71 rrfb4.R,�k d..> e.w«„�� Y' • p� y;�..,r ��e/4y.v e . .� .. . '1��k». .�ti`}; �.a 3 e's`�"`i`a7 �,.��e�>�.. /� !}(, . p � A..' , .i•• ., : , ` . ! 1'W'•�� . . .�.� +J�y�F`'�('rYw �'.�b-'V iW� ��� , �� ` p . �..: y .. . . � . ,.,��.. ., � . ' .. ., _,XUTF ibRIZATION NO. � �� C� DAVIE COUNTY HEALTH DEPARTMENT �, . , . � Environmental Health Section - 'PROPERTY INFORM�ATIO�I�T" � ...,. � Permittee's�` P.O.Box 848 ��'CO ��. ' ` Name: _ '$o� ' ' � Mocksville,NC 27028 Subdivision Name: ' Pfione#:704-634-8760 Directions to property: '�-��,"� t ��"►s� '�G41'� , Section: ` Lot: ` AUTHORIZATION FOR �il2r� i-.�o �(Z.r% �"'tts,"�1:r*.1 � �v WASTEWATER Tax Office PIN:# _ _ ' i {T SYSTEM CONSTRUCT'ION '�� , (.)/��c�L(��15� �.. o ���;..3 C�it� Y'�" � �..�%�T RoadName: �f-+Y� 't70��ip: �'L� �:+t�� fi ' **NOTE**This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Sec6on prior to issuance of any Building Pernuts.This Forn�/Authorization Number should be presented to theDavie County Building Inspecdons : Office when applying for Building Permits. . , . (In comphance with Article 11 of G.S.Chapter 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) , a-_,...,,,,, f_ j - _,,.. _> .A � '�� " ' ` ' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION , ' � , � ,.,,,P ' IS VALID FOR A PERIOD OF FIVE YEARS. ENV RQN HEALTH S .ECI L T DA ISS ' � , _. .� D � ... . . - --.s a;�,d .`j"�''h. �+�"i �d{"���, r';�: " t � n v'`^ �F �+7d�� °� � r� .. . � r �c ' . - .- _ . �y,`'d-$ .4 _ . . r'�.u. Yf�. 1� - r 9,�„ti�� . ""'+,tirF 'µ � •-:.. , .. �,r �:.. ...,v . ..: tm.. , �,�i Y �. w=�--�`" �� .: � -��-��� DAVIE COUNTY HEALTH DEPARTM T , � b � ..�x �-� .y �� '�..� �..'..,.�_. �Z�•}'y� ' ""� �",;�_ :-,-<-+'r� IMPROVEMENT AND OPERATI N PI�RIYII�'�_.. �ROPERTy INFORMATION -��• ' � <�,ertriittee'.s __w_.._... �^, , 1------'"'" �G . `, ; � ::N'ame: ""' � ��;;:e,.3 � � 1.-,��`"�� s Subdivision Name: r ;' � Directions to property: ��q.�. � �'p'=� "'+�° ��>"°-�`��; Section• � Lot: � Ilb11PROVEMENT �1�,:�:,,'� �. �� ��ri:� ►. 2'-,:"�,.c� M� Tax Office PIN:# ' .. � � 4 ��:: PERMIT - - ; . , . _ _ �� ;� � , , � � � w � �.---a ���'�,+� c:��.��.�->�'�, �. l��:, #'�,s,;, � c`.�. ..� .,� K�r,,� t,,.c, � Road Name: ���'...51 ��cS����Zip:�.. .��rn:.r�,:.. : **NOTE**This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system.An AUTHORIZATTON FOR WASTEWATER SYSTEM CONSTRUC"TION must be obtained from this Department prior to the ! construction/insfallation of a system or the issuance of a building pernut. ;, (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Sec6on.1900 Sewage Treatment and Disposal Systems) - I . : �Y'.;E +""�'*i. f`��"'TM~"" �,/° ***NOTICE***THLS PERNIIT IS SUBJECT TO REVOCATION IF SITE j '` .., #;1 , �� ,� r:r ,'�` "`, /� >_�.�"� ,.H^j PLANS OR TAE IIVT�NAED USE CHANGE.YOUR WASTEWATER , � ENYIRON���NTt�.�"HEALTH SPECIALIST DA ISSUED 5YSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE � �r' . INSTALLING THE SYSTEM. "" �... �_ � RESIDENTIAL SPECIFICATION:BUILDING TYPE ��� #BEDROOMS � #BATHS ' � #OCCUPANTS�GARBAGE DISPOSAL:Yes or !o i' ' ~.U� COMMERCIAL SPECIFICAT'ION: FACILITY.TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No� . '�, LOT S1ZE '� ���Y'TYPE WATER SUPPLY�l�a� DESIGN WASTEWATER FLOW(GPD)�� NEW SITE REPAIR SITE •�""'�'�' .�..:: � r �i;� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH^-•�'+ ROCK DEPTH +� � LINEAR Ff.��'�--' ';. OTHER � �i"i'�.•�fif� ��-i�r.,;;� ...w � REQUIRED�SITEMODIFICATIONS/CONDITIONS: ����'�/.'aLL :� C-�'�'(�'�L , �+'+-�,` �� � �'I.C;>�• t.."M�''P-� r;�` �,"�e"ti.;�4 IMPROVEMENT PERMIT LAYOUT �� ; . ' ``t�- `� '` � � , �"'��.. �` � G ("k rso.}'�' � � ,4' P1�t��«� i . �� ; t:�.c,<r �`�Y�,� " ` " �. , ��'�� ��.,1t,",SC���`�t2�� ; � . � � !Dc"� �� � . � ��...�..,�o ' � � **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTIOI3 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. w OPERATION PERMIT �� j� /_, �� SYSTEM INSTALLED BY: %A��� w��!A LL.V� �fl FF.�+.,a�t' � l,1 f`Pi:i1- L.��� �.� I. ��� , . ��� F�cz.s'�' a , . 0 � � \ J �� ^�� '�-, E�1J, ,1� ,��L^'1.�y4r�. , . . _ ��y `1,.� ��,.r- ..,...- _ .. -- , , � �- � � ` �` �r---�. S�,�c.s 'F5� �L�� -__ �p' 6< � Co^�T2�C.Zv�., , �• �.�� 'ro 24�^.� . � - .. AUTHORIZATION NO.�_OPERATION PERMIT BY: / DATE: �� � **THE ISSUANCE OF THIS OPERATION�ERMIT SHALL INDICATE.THAT THE SYS DESCRIBED A HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECITON.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 OS/96(Revised) ,� _.. } f.;. i �'�lM +• "`�:` � s,�'� t� i.'" .� '' a �y'a �T.:�., r u t i.+4"�£�` .s:t- . +,.r..l t�w:���.,t`�H �.i'.� ,t" �L� "—,1 ~`�„yR r � _,1..`v�.� . . . .. 'S' y . . .. 4'v�r�'��+nw.' '�z w n y��.. . . ..�- ��`, sY f . � ��..��� . .�� . . � �,.� .�. ' - ,� ��y- �.� DAVIE COUNTY HEALTH DEPARTMENT- -_- .- ,.,,.-�,� �n;3�r ' ""`°" �"'�-- -� �-�.:,=-` �' 'IMPROVEMENT AND OPERATI N PERMITS PROPERTY INFORMATION '�-���. ,'�ermiftee.'�:`�`�.�"_._: �� . : �'O �- � ..,,...N�me: '' . ��'�'�. �€:�'..,:.,,,-��r� Subdivision Name: „ .., � �. �Directions to property: ���>+ � �'�'' "���: ���=#� Section: Lot: Il14PROVEMENT , .,._1 v�ir.,,.'� ��p �t�.?� '�`:::';t•.,"'t'�:,�.,.? f�, j�s : PERNIIT Tax OffiCe PIN:# _ i f }a �` � l.)t�a�'c:��ti�".��� L..�r� i4�,;,"'� l��:�.,i�� ��"E7' c""'� �,,,.�::.£`t Road N�e: ��.�'t� ������'Zip:����t�"� **NOTE**This Improvement Pernut DOFS NOT authorize the construc6on or installation of a septic tank system or any wastewater system.An AiTfHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the � , construction/'installation of a system or the issuance of a building pemut = (In comphance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,; , . . � ....1�u... � v�..( . . . . . . � . . . . ' r-��,, "'a �!'""""'""�-..; f +'**NOTICE'�**TI�IIS PERNIIT IS SUBJECT TO REVOCATION IF SITE . t4,,� �ti, ��, �� �,•^�,�,,^':;' w ,�,.� � PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ,i � ENVIRON f�I''fC�.�HEALTH SPECIAL 5T DA ISSUED SYSTEM CONTRACTOR MUST SEE TI�IIS PERNIIT BEFORE ��r t..� INSTALLING THE SYSTEM. •. RESIDENfIAL SPECIFICATION:BUILDING T'YPE� #BEDROOMS � #BATHS �- #OCCUPANTS�GARBAGE DISPOSAL:Yes or� COMMERCIAL SPECIFTCATION: FACILIT'Y TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No '; LOT SIZE `F�`'-�'TYPE WATER SUPPLY�V�� DESIGN WASTEWATER FLOW(GPD)*��'� NEW SITE REPAIR SITE �+""�'�� . � ,� � SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH��I ROCK DEPTH �z LINEAR FT.�G'�/ . OTHER � �'...�'1�+�3'TI� +.:�s-SCt,�.� REQUIREDSITEMODIFICATIONS/CONDITIONS: ,��T�.�r. �°'� �`���� . ��- fl� '� i��� �►"4'�'� IMPROVEMENT PERMIT LAYOUT �� I � T. . I ��� . . . : �4--� F��t���c'. � t�us� � a�'�� -� ' �30� 5�c"� � ., �z., . _ tGb .+cs� u ,-� /oo , : ��� � **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. OPERATION PERMIT �� j� - 1 n y� SYSTEM INSTALLED BY: %AN�� ��l 1 A�-t3,` �0 �-++�T . �Qp�.,� ��li:S �.,.� .: 1 �0�� FIQS i ` � � � � � . � t/'r �� �A t��� _ � �- � � �� go• �,�� �� $o' �= co��.a�Q-,,�L�� ' , .. �Z�• �,�-ro 2-4�^� AUTHORIZATION NO. � d OPERATION PERMIT BY: DATE: �1 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS 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 WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OSN6(Revised) � � �.' . . � e�, ` , � ,,�.- � � L� � , �a , , � DAVIE COUNTY ENVI�ONMENTAL HEALTH SECTION _ � WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT NAME O 4 PHONE NUMBER �913'oS � 7� ADDRESS I � I � �J��SUBDIVISION NAME F1�lv• ��oa � . SUBDIVISION LOT# /� ► , ����� DIRECTIONS TO SITE ( � �i�� l?-1L-���rf'�X�6�� �CL , , ��. �� ���� , ��'. ��'�- /�-��� � �/ 1 5-�-� �. I�—. ��. a-�—l��- q. �-a-�-� DATE SYSTEM INSTALLED � � / 7 7 NAME SYSTEM INSTALLED UNDER ' ��'� ��� SPECIFY PROBLEMS OCCURRING 2!� V�-- �.��S�'�IS DATE REQUESTED ' - / � INFORMATION TAKEN BY �B� �, w � �� / �� � �