2528 Liberty Church Rd... e .;,,�y-y+^'� ry .7 _. .: .. ..... `;'`. C•'' � ':.par-. ,-*-..i+• _�,.:.. _ ..i.: �, .. -. .ifs _7 ts'iD �'i•re '? a �,;..
AUTHORIZATION NO: 8 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
PerrAit;ee's .SR P.O. Box 848
Name:; / Mocksville NC 27028 Subdivision Name:
Directions to property: T' ���'��X �'i " Phone # 336-751-8760 Section:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
/y4 SYSTEM CONSTRUCTION
Road Name:
_ Lot:
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 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)
ENVIRONMENTAL HEALTH
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
IST
DATE ISSUED
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
fi 7/1 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS , PROPERTY INFORMATION
PenrAiaee's .
Subdivision Name:
Directions to property: 1 p + .^ Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
Road Name: 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 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 UiTENDED USE CHANGE. YOUR WASTEWATERENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE f' # BEDROOMS_'"'� # BATHS -- 2> # OCCUPANTS 15;;l 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
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH /ROCK DEPTH Itf LINEAR FT.'
OTHER
REOUIRED SITE MODIFICATIONS/CONDITIONS:
"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 (75141 h3#jfR6t1.t )t
(77-r)'751,EZ6 i
I OPERATION PERMIT
SYSTEM
W �I M 'J
f
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: y
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I1 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)
t
DAVIE COUNTY ENVIRONMENTAL Lt� &l V11 N �
APPLICATION FOR IMPROVEMENT Ti (REPAIR)
NAME • �—f S /'�- / "-r t,L-e z� NE''Rl9MB2R UUI I %4�
ADDRESS - Z 1 b cr CZ �L • UBDIV.ISION !'N,AMEi"
v t 11 •17
LOT #
DIRECTIONS TO SIT i -71&-w b l e- 4'' "'k, 6• G� �"i'
15yrs � ?
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER �� E ✓ �J
TYPE FACILITY NUMBER BEDROOMS - NUMBER PEOPLE SERVED
TYPE WATER SUPPLY(-!/ SPECIFY PROBLEM OCCURRING
L / M
_ Cc- � �_ Tom"- c L L r �' vim. /fit, s Q �.._✓ � _ � S .6c I' C e C% e c- n d e r
DATE REQUESTED� 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_ C�� Lkl� . 1Y'\ k- M
Rev. 1/93
J DAVIE COUNTY .HEALTH DEPARTMENT
Environn•►eiital Health Section
PO Box 84f:."1'10 Hospital Street
Mock; -Ple, NC 27028
J l
Phoite, (336)751-8760
ON-SITE WASTEWATER CI.RTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: 1I'�P/S /i'/``l. l__`// '/ Phone Number:__---�� S���C� (Home)
Mailing Address:1
Detailed Directions/To Site: "I �� ��;y, r• � �'�� SS _�"��' ! -
Property Address:
Please Fill In The Fallowing Info tion About The Existing Dwelling:
Name System Installed :Jnder: cr�i?f�I/'F' � L9 �% S Type Of Dv,r iiing:
Dr to System Installed(Month/Day/Year): Number Of Bedrooms`,_Nurnber Of People:`
is The Dwelling Currently Vacant? Yes ❑ No ❑
If Yes, For How Long?
Ary Known Problems? Yes ❑ No Fe— If Yes, Explain:
Please Fill In The Following Information About'. -,he New Dwelling:
Type Of Dwelling:_? Yi Number Of Bed rooms: Number Of P: ople:
Requested By:
/V-, M
For Environmental Health Office Use Only
Approved ZDisapproved ❑
Environmental Health
Requested: 5 2-iZ ��
"The signing of this form by the Environmental Health Staff L; in no way intended, nor should be taken as a
guarantee(extended or lirnited) that the or. -site wastewater st-stem will function properly for any given period of time.
Payment: Cas _ Check ❑ Money Order ❑ # Amount: $C�7/• OJ Date:
Paid Bv: 7�, �•��✓r Received By: z
Account #: -1 y _Invoice #: /