356 Powell RdPermittee's o'er' -'
i �Z-r
Name:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O. Box 848
PROPERTY INFORMATION
14
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Directions to property: 1 ^ s e Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot: _
AUTHORIZATION FOR
,' ,• ;.. r.+ �J i WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 0 Q 2 0 M A Road e:'f'1uel Zip: 22 24'
**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
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS`T #BATHS # OCCUPANTS _� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE 2' &' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW NEW SITE REPAIR SITE^
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �rROCK DEPTH % LINEAR IFT �- �_
OTHER (f>•` ;'r"'�i "J'._S�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAY UT
*L� C V 6 1� pod,
PA ,
c AO&
f,
qoI�
11 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. 11
I OPERATION PERMIT
1b
' A
BY:
171
AUTHORIZATION NO'A'— t OPERATION PERMIT BY: � `� DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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.
DOM 02102 (Revised)
Permittee's r'''• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O. Box 848
PROPERTY INFORMATIOj 1p
ri,
Directions to property:(/ r . Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: bot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# C to
�+ a.
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 0 0 2 SS, 4 \A Roadame: TjIy 1 I PO Zip: ??O Ze
**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 1 I 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 TYPE } # BEDROOMS 7 # BATHS _Q— # OCCUPANTS / GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE` # PEOPLE/SHIFT # SEATSj INDUSTRIAL WASTE: Yes or No
LOT SIZE 2' Ot • TYPE WATER SUPPLY 1 _r? DESIGN WASTEWATER FLOW (GPD) �_fe5 NEW $ITE. REPAIR SITE
' f ,
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 'ROCK DEPTHf'!'. LINEAR FT:'"iz
OTHER /
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAj UT
11rT t 1� yeti
�� v' t
�D �a°'� o I
ry� A
� >)V p
D71
II 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. u
l 1,. N
OPERATION PERMIT
SYST LED BY:
1 �1
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 02/02 (Revised)
0114(Nol 7Lj4j D/61/ee W74(
` DAVIE COUNTY HEALTH DEPARTMENT
(� Environmental Health Section
r - PO Box 848/210 Hospital Street
2 200�j 1 r Mocksville, NC 27028
Phone: (336)751-8760
p,E�'ZA�PA��tl
ASTEWATER CERTIFICATION FOR DWELLING
e) REPLACEMENT ❑ I REMODELING M RECONNECTION ❑
/ rr �Spr�sc clNC�C'NscCl McJ-
, 3,gx, i=tip, l Srni-1 /j I
Name: (_4 A i / Phone Number: A 3 6 )1'7;4 -A-163 (Home)
Mailing Address: _ $ {, Pl) VA)C (/ Rd �j ��` _7 _r (Work)
%h'5 ✓ r /l E r Al L_ A. 76) A si
Property Address: A .5 (a R,(_ LIC :fib Y !) A
Please Fill In The Following Information About The Existing Dwelling:
�j
I UL
Name System Installed Under: STAyy e- S f {. To N c ---T Type Of Dwelling:L�� `�! o, C
Date System Installed(Month/Day/Year): - / `/(.Ci Number Of Bedrooms: Number Of People:_
Is The Dwelling Currently Vacant? Yes ❑ No X
If Yes, For How Long?.
Any Known Problems? Yes ❑ No V If Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
hWi� izj) c -P Afi4bl_8G Rco►',',, Gncr44 /?c00- cl n L
Type Of Dwelling: AQ fri i f Number Of Bedrooms: / Number Of People:
Requested By: ,�`'� ; l� �f� Date Requested: 6 " �. 6 D
(Signature)
For Environmental Health Office Use Only
r
Approved Q' Di,Mpproved ❑
Environmental Health
G
'Ihe signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By:1l,, Received By:
Account #: �14 Z T Invoice #: 652
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