134 Old March Rd Lot 3 Au H ATION NO; 9 Q DAVIE C "UNTY HEALTH DEPARTMENT
nvironmental Health Section PROPERTY INFORMATION
Petm�ttee'sP.O.Box 848 /
Name: 4
Mocksville,NC 27028 Subdivision Name: P ' Ol. fi"
Phone# 336-751-8.760
Directions to property: Section: Lot:
AUTHORIZATION FORWASTEWATER
. .r
SYSTEM CONSTRUCTION. Tax Office PIN:#*• F'
Road Name .f' ip: r, fQdSO
*NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
o 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,.
.t ! DAVIE C OUNTY HEALTH DEPARTMENT
IMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name. r '' j?/Y' 1�' sf� e � • Subdivision Name: / G' a ,
Directions to property: �' Section: Lot: "Y�
IMPROVEMENT
PERMIT ! Tax Office PIN:# - -
Road Nam � '`' :.' It-;e 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 .
constructionTinstallation of a system or the issuance of a building permit.
(In compliance with Article l I 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 INTENDED USE CHANGE.YOUR WASTEWATER
:ENVIRONMENTAL"HEALTH SPECIALIST, DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE /7' .#BEDROOM #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 ` D DESIGN WASTEWATER FLOW(GPD) > NEW SITE REPAIR SITE.
SYSTEM SPECIFICATIONS: TANK SIZF/�GAL.. PUMP TANK. GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.• Od
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTERe t[USFR(S) IF 691 BELOV FIRISHED GRADE*"
*'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 PERM
STEM INSTALLED BY:
o �
CY
J.
�7
l /
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AUTHORIZATION NO. 191d OPERATION PERMIT BY !/ DATE:
*'
TILE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
ATM ARTICLE I 1 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
•' % Davie County Health Department a R
Environmental Health Section
P.O.Box 848 _
Mocksville NC 27028 8 ,p
ENVIRONMENTAL HEALTH
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEILUNLESS DAVIE COUNTY
ALL THE//REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed /�',� NOC28 of C cw-Sr..TA/C . Contact Person
Mailing Address UJIAlG- 1-*9VI:E ZAl Home Phone �i�' -7S7`1
City/State/Zip ,'MOC-e-5 t/" LC C 7U o2 S, Business Phone 3 9Rg-7a7`I
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: f Site Evaluation . Improvement Permit&ATC O Both
4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry O 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: X County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? O 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: R,97— 00eQA1 zg/V CC OScU I WRITE DIRECTIONS(from
_ A s��ille)TO PROPERTY:
Tax Office PIN: # 7 ofa - -76- - "5-6, 0�
/+ 1 15-8 7y $6/ -
Property Address: Road Name PC4A PQ. 1
1 /eT 7-0 1-9QVAn/C-e-=—
City/Zip ADV gA,CE_ C a'7006
1 7ZUZrU L�i=r- pN �,cU/�u.;g
1
If in Subdivision provide information,as follows: 1
19WC9& Ab
Name: 1",4"X14 MOODS 1
Section: Lot #: ✓' 1
1CJn,1Js OW 2r.
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.1,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 Woo 7—C to conduct all testing procedures
as necessary to determine thesitesuitability. �7
DATE 6 — 6 ^ 7 & SIGNATURE
Revised DCHD(06-96)
JOU MAY USE THE BACK OF THIS FORrt FOR DRAWING YOUR SITE PLAN.
----- / / �;, SIDNEY F. HOOTS
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NOTES
61/ ALL LOTS ARE SUBJECT TO DAVIE COUNTY
/ /
/
%� / / / / ,/
HEALTH DEPARTMENT STANDARDS
ROADS ARE TO BE
2. _
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