1561 Main Church Rd ,X.. '„y,Wq;;�f;aFr`v^f•,1��:b` t3,,r ti�-.yv zt+p,rp^+r amu:" s� +".f.t''� ..r N7•w-`'�t �'+ib Zz .: '.f'' ''"-i'xdn .�. ;':_..:i-- i .'xt.r -c:: J }°.'ti'-5...� ' ' 1£'c e-. /� .,a
AUTHORIZATION NO: 0904 DAVIE COUNTY HEALTH DEPARTMENT
,..p<
M. ` Environmental Health Section PROPERTY INFORMATION
P.O.Box 848
am: ' "s�'N-5r2 • � � Mocksville,NC 27028 Subdivision Name:
` ,, Phone#:704-634-8760
Directions to property:L o t N M P� �.�� Section: "'" Lot:.
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# - -
' Road Name�r��
**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
IS VALID FOR A PERIOD OF FIVE YEARS. `
ENVIRONMENTAL HEALTH SPECIALIST, / DATE ISSUED
!� ..�,.:;o ... - r,,:,._ ,F•Z;'t F v{ } r.; ay.+r r!vrYi" �, ..:i.;_ fy ''L. �+; x.;.:.- 'a .r:t,.F.;�. r..:�;-;:dwrl.-:- v" lv.�..-,,, f} - n'',�.
it k� t,1 '.i . Y is 4. +'r ,` i nT:`7_.�wi l •/
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
> §
( Subdivision Name:
°Name "
'Nit'
Directions to property: !`y ) �,� :;.2cti Section: ., Lot:
i_. IMPROVEMENT
X: PERMIT Tax Office PIN:#
Road Name �1 c ,�, ��� .,� Zip: + 1I r
**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)
� C ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
' i 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!�k,—VOP#BEDROOMS i�L#BATHS_!_#OCCUPANTS�_GARBAGE DISPOSAL:Yes o0
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 V
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH_� LINEAR Fr.c4
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
C
1 '
G C
C o
"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
SYSTEM INSTALLED BY:
I
I
D e>�
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 05/96(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT S ,
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Penmt ee's.a.
Name: `` Subdivision Name: ""
Directions toproperty: r t
Section ' Lot:
4' IMPROVEMENT
PERMIT
Tax Office PIN:#
Road Name.'a F• ,* Q t, E Zip:,-"'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)
3 -I ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
:w,::! s P PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDE13TIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #B(1TI,IS_�#OCCUPANTS I GARBAGE DISPOSAL:Yes OrAl
Y {
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEI/SHIFT #SEATS INDUSTRIAL WASTE,:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) �' b NEW SITE REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. V
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
`T( h 1�
J
S
O G -
v
**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
SYSTEM INSTALLED BY:
i'
a.
`Y AUTHORIZATION NO. (✓ G OPERATION PERMIT BY: +�/� DATE:
**THE-IrSSUANCE 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)