132 S March Ferry Rd Lot 24 v♦ r,:.r "'+-Ffp. -*-..3'b rnan,'v.v+1: ..Y,j`y''+.y i..,...t na7 t�i�^+ro '6 .'.,�v;rN�`}H'' i17 �." ! �Pc.:..'..."tr:.1....b � i5-,%_."�' L"� r� ;,� ,... ta+ _..r a..e'{I
AUT IORIZA7t0b1 No:
1978 DAVIE CUNTY HEALTH DEPARTMENT
environmental Health Section PROPERTY INFORMATION
Permute 's `- P.O. Box 848
Name: Mocksville, x 8 27028 Subdivision Name: �`
,,/ Phone# 336-751-8760 +
Directions to property:' �r% %'l z4 t o//S- Section: /� Lot:
AUTHORIZATION FOR
WASTEWATER , Tax Office PIN:#, � -
SYSTEM CONSTRUCTION
Road Name: &AA944-04i :
**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 SPECT LIST DATE ISSUED.
4 irs'T' r -.-...s _., t ..y.` .sa-� ( ;N c--. ^t- - T:,.•'-s ;i , ..:; r ., ., ,h
DAVIE LINTY HEALTH DEPARTMENT
1 978 '
IMPROVEMENT AND OPERATION PERMITS- PROPERTY INFORMATION
erttltt s
Subdivision Name: �/ s� 4'
`Directions to property1
/! Section: / Lot: s.
IMPROVEMENT
PERMIT Tax Office PIN: j ,
"Y Road Name: 1,..5",+
*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)
f ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
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 A/ #BEDROOMS _7 #BATHS .L #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFr #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY /10 DESIGN WASTEWATER FLOW(GPD),-740 NEW.SITE L, REPAIR SITE
SYSTEM SPECIFICATIONS:TANK SIZE T/D GAL. PUMP TANK GAL. TRENCH WIDTH -5e ROCK DEPTH ,..�'LINEAR FT. OD
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: "y
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLtJERT FILTER* *RISER(S) IF 60111 LOW FIRISIIED GRADE*
3x41
nn ,
.00
vu ®
**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
SYSTEM INSTALLED BY:
IV
60 70
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 05M(Revised)
41
-' APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERF M R
1!1 L5
Davie County Health Department D
Environmental Health Section
P O.Box 848 JUN - 8 1998
Mocksville NC 2702
(7 3 6)7 760 ENVIRONfAEtITA� ERL?N
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES 40
ALL THE REQUIRED INFORMATION IS PROVIDED./'�� n
1. Name to be Billed / � NDC2S O�C6y3T.TNC . Contact Person.1C/e
Mailing Address e?Q S W/ill G- tZEEAl Z Al. Home Phone - 7S7'7
City/State/Zip motes ✓!e e_C /.C ?70 a S% Business Phone 3 fIqV-7.Z-77
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: K House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: . # People # Bedrooms -3 _ # Bathrooms
Dishwasher ' 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 P. ATMTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: RA7— 004,4V E!V CLUScd 1 WRITE DIRECTIONS(from
� 7 �, g - � - 5�8 S M cksville)TO PROPERTY:
Tax Office PIN: #
Property Address: Road Name
1 /eTro /-90 A
City/Zip AD✓AA)CE_ Al. C d-700 G 1
1 TZCIW pN
1
If in Subdivision provide information,as follows: 1
ito Ax Ox
Name: MA Q CN 60060<. 1
1Z /YllCf.S
Section: Lot #: Z 1
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. 1.hereby,give consent tc
the Authorized Representative of the//Davie County Health Department to enter upon above described property located in Davie County
H
and owned by �D/-/.,y . WOO T--<- to conduct all testing procedures
as necessary to determine thesitesuitability.
DATE 6 7 SIGNATURE
Revised DCHD(06-96) '
JOU MA1J USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. C/ ��1%J •��
Am/� 6`0
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X14 V ' >E
NOTES ?
61 ' / 'i ` ' //.'/ 1. ALL LOTS ARE SUBJECT TO DAME COUNTY
HEALTH DEPARTMENT STANDARDS.
i I/ r ' 2. ROADS ARE TO BE BUILT TO NCDOT STANDARDS