201 N Pino Rd� cr^Y _- K,.Vx J.N ,�a<-.r=a»rrr ..��.w .g� ,•+-a-�.,•�... z. .... .... t, t.i;:. :%ih�`-. ya ti ..
r,r+.� � �`�t' m "'w��w?;.'Y �r.s:�i' � F�' '1-f�r�•`. t.;n='y.%'"w,.Y.sr� ,'?P `"'r�'lt1
Permittee 6- i, § i DAVIE COUNTY HEALTH DEPARTMENT
- Name: Environmental Health Section PROPERTY INFORMATION
«:.....,.*, - P.O. Box 848
Directions to property: -�16(i Mocksville, NC 27028 Subdivision Name:
t: Phone #: 336-751-8760 )
k i r, j !'+ 1 / r r: fU s f; % Section: Loi:' '
AUTHORIZATION FOR
WASTEWATER
�; r+L Tax Office PI :# 1 -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 00285'5 A Road am e: ► 140- 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 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
RESIDENTIAL SPECIFICATION: BUILDING TYPES +_ # BEDROOMS # BATHS #OCCUPANTS Q GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY WC DESIGN WASTEWATER FLOW (GPD) &L NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE )100C -GAL. PUMP TANK(/!C-'-0-GAL. TRENCH WIDTH �L ROCK DEPTH a LINEAR FT.
,.-�`. TUFA /�11r��► ► t.�n lnC)i) � �f r rr-..n.�'I �c� ei5 � {.��;-�.. �'�, � �'�.<'1-,®w., _
REQUIRED SITE MODIFICATIONS/CONDITIONS:
i
tub 1 Y3
op.
tie
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
(G` SYSTEM INSTALLED BY\ `!�f �� A G Q to ?'
i
Nc-
�i �S� 1A
-5kc;\'e
6 �'O 69
7-1
+ DATE:
AUTHORIZATION NO. OPERATION PERMIT BY: /
STE $ A2 � dt
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY ri SC �E EA24'&S HAS BEEN INSTALLED IN COMPLIANCE
WITH 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 02102 (Revised) - k1 7 ! ;d 56/5 �TA y - b 7 79
b< he A�f� .
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION •� Y-O�'
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME / 1 l ,�/I Moy n ZO u /eS PHONE NUMBER
ADDRESS ,�20/ Ali IV- SUBDIVISION NAMEC ` � ` I 1,
LOT # ✓ C.; / L P-9 l
DIRECTIONS TO SITE (a 0 / -N--.t ruf1y 0 ((,�ina la -A e n
iii / l In i le dA) N*IA KJ IM - O N 4e*
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER &41.5 OR- Le uJlCIA
TYPE FACILITY 6fQS e - NUMBER BEDROOMS L�NUMBER PEOPLE SERVED a
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING Me a;( eN�
DATE REQUESTED `- 0 1? INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
0%,
understand
�j%II am responsible for ►charges incurred from this application.
01 . {'
;_A4 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION.
•NO`TE:.Issued in Compliance With Article II of GS.Chapter 130a h
Sanitary Sewage Sy temsPermit' Number
Name s �.1��. A7eQerVrA *Dated ? r"zi-1's N2 7921
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size _ — House Mobile Home ---- Business _— Industry
No. Bedrooms —.No. Baths — No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO Q� Specifications for System:
Auto Dish Washer YES ❑ , NO ❑
Auto Wash Ma^hine YES Q NO ❑ �o
Type Water Supply _T
This permit Void if sewage system described belo is not ' stalled within 5 years from date of issue.
This permit is subject to revocation if s'te pl'3 or th inten d use change
ATTENTION: YOUR SEPTIC SYSTE TRA S THIS RMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM..,N�V °�,
i
/v>ents
Im permit by --
*Contact a representative of the Davie C/punty He6tl,h Dep . t for final Inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on da of com let le h ne Number: 704-634-5985. j`/�(C?
Final Installation Diagram: -4—q— — System Installed by
M
'r
� Y r FyA
F
Certificate of Completion — 1 __ Date ' luglh.4 _
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
caticfartorily for anv riven Deriod of time.
• GoMaps GIS
. . _ I i
ONE"
IPIPTF'�. f
L
r
Page I of 6
A
http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=17813&CFTOKEN=49736857 4/9/2008
FAX MEMO FAX MEMQ,
From: Environmental Health Section
Davie County Health Department
P.O. Box 848, 210 Hospital Street
Mocksville, NC 27028
FAX MEMO
Fax Number: 336-751-8786
Phone Number: 336-751-8760
Date: \1/20 �- No. of pages /
To:
Fax number: LI,
b7—. q7O2,, -
c
nnr .rr
e Aele -
k DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION O
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) -"J�
-;,A NAME / �'l e t �SEO IV Q 1�( l'l-f L.� Ll. �C.S PHONE NUMBER
ADDRESS_SUBDIVISION NAMEM�l
¢
LOT #
DIRECTIONS TO SITE l� Q Al,_�ll %/ll ("'Wi r 1,41 ` 0 end ai1�r�
W l l 114 1le. 1�fA) Nff4l SND - 7 NO( OA) 1-e4f
DATE SYSTEM INSTALLED 1177- NAME SYSTEM INSTALLED"UNDER C�G(�frS DiZ ��2lcdi
TYPE FACILITY / Qt(5� NUMBER BEDROOMS NUMBER PEOPLE SERVED a
TYPE WATER SUPPLY / SPECIFY PROBLEM OCCURRING d/IIC I;Ale, a 0N4
A .. /
U
DATE REQUESTED #4 INFORMATION TAKEN BY �CP%
This is to certify that the information provided is correct to the best of my knowledge, an at understand I am responsible for
SIGNATURE OF OWNER OR AUTHORIZED AGENTRev. 1/93
&Oarlr
incurred from this application.