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` 'I'ARiZATION NO: DAVIE C LINTY HEALTH DEPARTMENT �/v .
r.,:,. Environmental Health Section PROPERTY IN RMATION
Permittee's P.O.Box 848
I : Name ry ` }*
Mocksville,'NC 27028 Subdivision Name: f'
� Phone# 336-751-8760 ' 9
Directions to property:�T - ,� , ��� Section:" Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# i°c� -
SYSTEM CONSTRUCTION
Road Name: ro NO
**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 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
% DAME UNTY HEALTH DEPARTM NT
PROPERTY INFORMATION
gip ") IMPRO EMENT AND OPERATION PERMITS
Subdivision Name.
.. /% �/ ' .
Dlrection`s�o'pragerty: r� .Section: Lot: �
IMPROVEMENT ,
- PERMIT Tax Office PIN:#
r
Road Name: 'd �G jr
**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)
ti ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
', ✓ >: /�;' % f% PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER '
K IEALPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HINSTALLING 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) ��� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZF/ GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
s
**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
A0 �INSTALLED BY:
AUTHORIZATION NO. � � OPERATION PERMIT BY: DATE: �o
**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)
x
^• APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& C
r ' Davie County Health Department OgIRO
Environmental Health SectionP.O. Box 848
Mocksville NC 27 2860****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UAVIE COUNTY
ALL THE REQUIRED INFORMATION IS PROVIDED./'l'� n
1. Name to be Billed ,�l AlDf-2S O•l)(.dy3r.-Z/C . Contact Person Aelc: /-{•t/O $DAl
Mailing Address o7a S W1 Al G- 47 t/,t�-7 Al LA/. Home Phone ' 7s 7 9
City/State/Zip .&Qct 5 t lLf-Ae �.C 70 a F Business Phone -:3--34 qq-7.Z7q
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: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _— # Bathrooms
Al Dishwasher X Garbage Disposal � Washing Machine ❑ Basement/Plumbing ❑ 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 ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PYATMTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: RoPT 0044V —=/V CCOScO I WRITE DIRECTIONS(from
,,Wlocksville)TO PROPERTY:
Tax Office PIN: # l''//
r1 ! 78 7v 8O/ - -°GeA•tl
Property Address: Road Name' �t=O�GE�3 C K 0Q0. 1
City/Zip AoVAA)C.=_ It/. C_ a moo C- ' �J
' 7&VW Lai=r pAl
I
If in Subdivision provide information,as follows: 1
A= Ab
Name: Aq�eCN won p
Section: Lot #: Z 1
/YJicE.B
I GU DAY �2r.
1
This is to certify that the information provided is correct to the best of my knowledge. 1 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.1,also,understand that I am responsible for all charges incurred from this application. 1,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 byL Of-,til! H Woo T-C to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 6 - 4?9- SIGNATURE
Revised DCHD(06-96) G!7�
YOU AIRY USE THE 13ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. L
SIDNEY F. HOOTS: /
i i A cp D.B. 175 Pg. 507
/ 33.47.22• / s
-------~r,_ / • E 231.61
-1. HOOTS t 00 t o'1 \\ /r' 'LOT,'#7
7/' /� /' ;' // _.
75 Pg. 504 �. i ,2e / , /' -- i j %� '_ �i t-`—
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/ 111 i ' ♦�// j I , 1 \ L
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It ' \ \ 1 1 �' ♦ r i / / r 1
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---- � /� / �'�� �/�' / ♦ i ,/ i i /�♦� i /'�....._� � \ N � �� \ �� � (PUBLIC)� � ' �t/1
LT--#2#------_—/ SIOHT "�� Ile ' / / i i%
LOT ' �' / ' ♦' / r4/ ' r ' r ' \
I� �o�,. �♦ ; / r //�� r I 1 r �"---- / I % % �^ ` LOT, #9 111
v I ( i `- 1 XOT ho
, 1 I u' 1 I 1 i� - � - --1 LOT it 1 i /
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TS d /// /// . '�_`�/ / / / 133 -�_�- ; r
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es
�'"_~' / ♦ i-- _,g9g — _�" �' �/ /d ♦ /,'moi/ / NOTES
/ Z- -/� ' _ / ' i'/�-�_- /i/� ♦/' /% ♦ i it /;�/ 1. ALL L07S ARE SUBJECT 70 DAVIE COUNTY
61/ /��= 1 ;1 r ,'/� HEALTH DEPARTMENT STANDARDS.
2. ROADS ARE TO BE BUILT TO NCDOT STANDARDS