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1157
AUTHOR"s7RiTION NO. DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's .... e P.O.Box 848
Name: - } 1 a1)Ar Mocksville,NC 27028 Subdivision Name: i'!'= ✓�
Phone#: 704-634-8760
Section: Lot:
Directions to property: '��' ,�'' ' ✓
/
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
Name: Zip:
**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
1 a ('iLL / � r+;.Sn..r �y,a- � -t+•y- y'W-1� '. n� . ti'i •� t •f -� �.` t �.
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11,
1157
✓tea
DAVIE COUNTY HEALTH DEPARTMENT
. ., IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name: .7;xn .q Subdivision
,.
Directions to pcope�rty: %%%:I s'.. R J Section: Lot:
.¢._ IMPROVEMENT
1 PERMIT Tax Office PIN:# -
•r ' /l f 2 dh i Name: Zip:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system.Ari'
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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r 4 R , t l x .a t �� -� 1 '� "'`iJ• PLANS OR THE INTENDED USE CHANGE.Y UR WASTEWATER `
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TMS PERMrr BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE --� #BEDROOMS #BATHS l2#OCCUPANTS_ GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE A #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE_ SIG TYPE WATER SUPPLY /`�y_ DESIGN WASTEWATER FLOW(GPD) NEW SITE 4W— REPAIR SITE I/
SYSTEM SPECIFICATIONS: TANK SIZE GS AL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.,J�e
OTHER 4Z�i 4d
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
k
L
c _
**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:
s X01
AUTHORIZATION NO. OPERATION PERMIT BY: /'— l� 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)
1157
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION y
N-
Permittee,s
Name: Subdivision Name
} ;
Directions to property: ` Section: Lot:
IMPROVEMENT
}' PERMTT Tax Office PIN:#
i�rl I
I� Name: 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
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)
a
` ***NOTICE***THIS PERMIT IS SUBJECT TO,REVOCATION W SITE
._ ,.. f "•- ,r'-'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:BUILDINGSTYPE —� #BEDROOMS#BATHS #OCCUPANTS 4/--GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LO1;SIZIu_ .Il TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR STI'E
�.r�// �
SYSTEM SPECIFICATIONS TANK SIZE l' GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTHr LINEAR FT. f
'OTHER
N
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT t
- `�.
l
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION O THIS SYSTEM
BETWEEN 8:30-,9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHON�#IS(704)634-8760.
OPERATION PERMIT f
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: f
"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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET
FOR SEPTIC SYSTEM REPAIR PERMIT
NAME ,`/� /1i4 a✓/'��� PHONE NUMBER
ADDRESS,?/2! ✓(�Gi7i �� SUBDIVISION NAME
SUBDIVISION LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c f !
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name 4Tr�-/r1 ,', .,,�/�. Date
Locatiori —
Subdivision Name /r� :'- r -/ Lot No. ,�_ Sec. or Block No.
Lot Size House —/-`--' Mobile Home.— Business _— Speculation
No. Bedrooms No. Baths ' r No. in Family_
Garbage Disposal YES p NO ❑ Specifications for System: J�
Auto Dish Washer YES NO ❑ x r _ �� .G� ,'
Auto Wash Machine YES NO ❑ c'1l/�..' `�
Type Water Supply _—
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by 'T
`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 day of completion.Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by_„
W
i
Certificate of Completion /� 'i / Date
'The signing of this certificate shall indicate that the system described above has been installed in with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
4 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone
1. Permit Requested By,, ADF-5 k/ x,.Lr/_3.4me's Business Phone
2. Address Wh1i rE N8.9_d D,-. , Z?eY 2350 l/r7.k/6&:-, X e_ 2-90016
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.�
5. System used to serve what type facility: House Mobile Home Business
Industry ' Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms ?.,�Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal t/
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Com unity
b) Has the water supply system been aproved? Yes No
9. a) Property Dimensions &1,o--
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge. /
Date wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)