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IZATIQN NO: 1 16A DAVIE COUNTY HEALTH DEPARTMENT
-? r i, Environmental Health Section PROPERTY INFORMATION
Permittees '` P.O:Box 848
Name: , Mocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760
Directions to prope-
rty: Section: Lot:
r AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# .i' i� f
SYSTEM CONSTRUCTION ---
Road Name: �4 Zip;Z 7d7�F'
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of Office when applying o r Building s.Permits.
(In
Number should be presented to the Davie County Building Inspections
y g
(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 SPEC LIST DATE ISSUED
,qY�DAVIE COUNTY HEALTH DEPARTMENT
e IMPROfVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Nam r"=rf Subdivision Name:
r , operty: `� f / r' Section: Lot:
Dit�ctioO,to prA ;+
) IMPROVEMENT
PERMIT . Tax Office PIN:# 1= `5 - r ' (
Road Name:, r f Z 7� r3'w
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 thy' l '.
construction/installation of a system or the issuance of a building permit. -
(In•compliance with Article 1 l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
? , r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
fi.< �•.' r r ,jr d? d f ." j' '� 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 #BEDROOMS T_#BATHS #OCCUPANTS_/—GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION:.FACILITYTYPE #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 SIZE,,&I—)GAL. PUMP TANK GAL. TRENCH WIDTH ?l ROCK DEPTH LINEAR Fr.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT &APPROVED EFFLUERT FILTERs &RISER(S) IF G•• BELOIJ FItlIS[iED G120V� .
STSy I,,/U -fi'c� � � Jl
P
"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;?=;Bi4UMC .
(335)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY: S M Vt��
t�cp
ST
• j Q
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: cJD
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT STEM DESCRIBED OVE 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)
* APPUCAIM FOR SITE EVALUATION/IMPROVEMENT PES IT&
. Davie County Health Department L5 v 15
Envit»nmenfof Heal&SftWon
P.O. Box 848/210 Hospital Street
APR - 8
Mocksville, NC 27028
(336)751-8760 D
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. 17sae to be GilledA C-U /,/. =: .;2&E Contact perm S111i*7.E
Mailing Address /1 Home Phone 7*- 41/18 RAO,
City/state/ZIP dO��f_ XA-1J-'E /!IG Business Phone 750y 4Ry7 ifl, oe
Z. flame on Permit/ASC if Different thanAbove �/}��' �S ��t7Ll,� 6r/ /;to
Mailing Address City/Biota7A;�
D0-4---f
3. Application For: to Evaluation �r emenPermit/ATC 0 Both
1. system to service: XHouse Mobile Home 0 Business 0 Industry 0 Other
a. If Residence: # People _L # Bedrooms � # Bathrooms _
Dishwasher n Garbage Disposal XRashing Machine Basement/Plumbing U Basement/Ho Plumbing
G. If Business/Industry/other: specify type # People # sinks
# Commodes # showers # Urinals # Rater Coolers
IF FOODSERVICE: 11 Seats Estimated Nater Usage (gallons per day)
7. Type of water supply: ❑ County/Citywell 0 ComML;4ity
e. Do you anticipate additions or eipatn`sions of the facility this system Is Intended to serve! )6es 5JO0
If yes,what type' �G� 1�_ nM C L12k; 1 F /.•y;�'4 .- ..� /ilo,�. �foM.E'
***IMMRTANP**CLIENTS AIUSTCOSIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN AIUST RESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: SEff
E tti4,r WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Taz Office PIN: # s7eSjl--q ?� (wlp) 401 -5- Ze— 6/,cx4L
Property Address: Road Name Pnw kd �r�,/iy dvtg/ (��cn_,e v /4,w
ed
citylzip/noc r-SVAC /,I��ir✓ 2 arj
If in a Subdivision provide information,as follows: �jo�ox �a-r,'/� Cllr��,a moo•%-��
Name: '3 one 'el-
Section: Block: Lot: Date Property flagged:
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 pians or intended use change,or if the information
submitted In ibis application is falsified or changed I,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 De artment
to enter upon above described property located in Davie County and owned by R
to conduct all testing procedures as necessary to determine the site suits
DATE 1T SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all or the following: Esieling and proposed
property lines and dimensions, structures, setbacks, and septic locations).
SEE /YT jLAG MFi✓'�• /* A)d eJ
hANJ a by, /OR-'4'V';0 ys 19 u Yes-
f1r-X-:W 0,4// /'1 F_ �� APP�. Tr, rA+ IVp 4f 4-/- s:'/,
My brie 20 ? Account No. �Zs
14,00 Y_ 7oy- 6V7- 49,0o Como
Revised DCHD(07/98) ,[�pf �a,� ,L Invoice No.
Lwvc tNOkdt
992 feet
M
o
b
I home Itank
777 feet e 3allem
existing drive 293 feet
future drive
817 feet
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