148 Sugar Creek Rd w-.,'i� vK!y+�;� i N*rt;-i�r-,•.a f».'•t i�r tY.d !�j r H "' i rr,i,' " s, � ^ . .<<.,'ry i -+' t ti i t ii': ."i4"x � 2 - -:
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AUTHORIZATION NO: 0875 DAVIE COUNTY HEALTH DEPARTMENT DO, I:H
• Environmental Health Section PROPERTY INFORMATION
Perriut2e's- d P.O.Box 848 Wi�A
Name: `�A NC 27028 Subdivision Name:
Mocksville,
Phone#:704-634-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER 11 SYSTEM CONSTRUCTION Tax Office PIN:# - '
Road Name: Q 0-r» .�ip:
**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
f:'")J✓..;,, `✓ia f� ��,/�� cam` IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEAITffSPECIALIST DATE ISSUED
r)�. i t�2Y t• i.•d"w Y`�i+°v'^/-,��:::?:,[.1.�ti<-•5 7 {ti.:u {"r 1..vr a,. �,r- rl � '^.;i
! ;
DAVIE COUNTY HEALTH DEPARTMENT ' �� N
�, ► '
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
f
Permi �� •.>
_ •Subdivision Name: _Ar��
Directions toro
P perry: = Section' . Lot:
-j IMPROVEMENT
PERMIT Tax.Office PIN:
#
Road Name: 14 CH . ,p: x � I
**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)
1 ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
t'`� r 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 DESIGN WASTEWATER FLOW(GPD),,T/10 NEW SITE // REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZI✓�_GAL. PUMP TANK GAL. TRENCH WIDTH ,?z ROCK DEPTH ,1�0 LINEAR Fr. X-00
.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"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
STEM INSTALLED BY:-
o v
i $ - 47
AUTHORIZATION NO. O OPERATION PERMIT BY: C� 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 05/96(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
J Davie County Health Department a R
' Environmental Health Section D V
P.O.Box 848
Mocksville,NC 27028 MAY 1 9 1997
t \ � (704) 634-8760
l l
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL
' THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed 9' /v �i�� Contact Person�1Sl'7-1119
Mailing Address 30 e 'f C" G Home Phone
City/State/Zip Yy1�i�S�/�- ?i70Z �' Business Phone���y—y5`9l
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation [Improvement Permit&ATC [ ]Both
4. System to Serve: [ use [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Re 'dente: #People #Bedrooms _ #Bathrooms [-]'Dishwasher[ ]Garbage Disposal
[ Washing Machine [ ]Basement/Plumbing [ 1 Basement/No Plumbing
6. If Business/Other: Specify type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers ,
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. Type of water supply: [ ]County/City LXWell [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes ANo
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***XV OF THE PROPERTY MUST BE
y SUBMITTED WITH UM APPLICATION.
Property Dimensions: l • ,/ WRITE DIRECTIONS(from ocksville)TO PROPERTY.
Tax Office PIN:Gio%4 535L- A117 - 7 J
Property Address: Road Name %
City/Zip A 7t
LL
If in Subdivision prolridq information,as follows:I r( / w% 11 us1
Name: LD01 ea&) 54A LOW � slo4 c' 7 �
Section: Lot#: K
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by ��5 t cond ct al esti rocedures as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD(06-96)
THIS AREA MAY $E USED FOR DRAWINC7 YOUR SITE PLAN:
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