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177 Reavis Rd . . ; � . . ,��,��--�i-�S �ermittee's �/� ,,/� DAVIE COUNTY HEALTH DEPARTMENT Name: ��'t��`� t'�5���k� Environmental Health Section PROPERTY INFORMATION ' �1� �� P.O. Box 848 Directions to property: L�� Mocksville,NC 27028 Subdivision Name: ��� �� ,,��i� ��`- �� %�.����� Phone#:336-751-8760 � 7 t � Section: Lor. AUTHORIZATION FOR ,t,T Ow1 �l- WASTEWATER Tax Office PIN:# - - SYSTF.M CONSTRUCTION AUTHORIZATION NO: �0 2��� A Road Name: ����'�"��)J �'�i ^ P; �.!7G`.`�._,�s **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior to issuance of any Building Permits.This Fomi/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In com�l ance��3itti Articl�I 1 of�'i.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ��-----�. ' :' ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION ' „ ''1---� —I��i q tG� IS VALID FOR A PERIOD OF FIVE YEARS. '�IItONMY IY u �tl S���I IS'[� DATE1SSt1ED , � , G RESIDENTIAL SPECIFICATION:BUILDING TYPE���}, #BEllROOMS � #BATHS � #OCCUPANTS ` GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE�����PE WATER SUPPLY �1"' DESIGN WASTEWATER FLOW(GPD)�� NEW SITE REFAIR SITE � �' �� ' ► SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH �Z LINEAR Ff. �'� OTHER---(_ _�1S1'Iz.) �IJT�JJ l�., � Q�T��T��G�'�o�V4�1f'c ` REQUIRED SITE MODIFICATIONS/CONDITIONS: 11�5�'/��-�' � �rJ���� !�/V� ��n.,�1��i�,L-, '"�.f �,F��" ��' . IMPROVEMENT PERMIT LAYOUT � '�Ie.uC ��u� a� �^a�.�J v-6►�. �-�p�,L, o� E?U STI�� ' 2�� ,.�.'U �. � S�S,�-.�r�-,�i5�, . s � , � ��t' ', �T►-l�-r �PP� �-�aG �-� ,��� �.1W . �� t�� �i 2.:5'i"" \=� �' � ,"1 t1DIA^�`k�ISTI.�(�) �./? • �.L�'_'—�'�.c>�i7�'�.:.1� � ' --- — N�v*� FR��.}T ��IM t"'� P ��'°.� _ ►�i V� 1 � � �'�- / S "� �_,�„ FOR FINAG INSPECfION OF THIS SYSTEM PLEASE CALL BEf WEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT /1_n ��.�(� �� SYSTEM INSTALLED BY: L?U J,� ��-'�� / ��,rl..W� !� , f �Q � �a AUTHORIZATION NO. �"�� OPERATION PERM Y: DATE: � 2� •'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE M DESCRIBE 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. DCFiD 02/02(Revised) ""W` � 3 / / / �/1,(� �" y0 �j- � Y' �. ... . .. ,:-` r. .- . - - , . . . , . . -� �. :. . �-. .� _ , . . _. � . .,.. . _ .. � J ; ^ ti - . t . . . . . . 6�.n.i''4` _ . . ,_ _ � . 'r:, .. , _ - .. ..,t �f+�.'/�./ l/ �� i�ermittee's�� `,y i DAVIE COL�NTY HEALTH DEPARTMENT �' yName: ''�1��� �''ti-`��¢'�t•� Environmental Health Section PROPERTY INFORMATION - '� --;_a � P.O.Box 848 •. Directions to pmperty: �f�Vt� ��� �'`�"� Mocksville,NC 27028 Subdivision Name: - '�� �� ��;:_� �k� r,,� ��n�i�.: i�� Phone#:336-751-8760 , R � Section: Lot: ' " � " AUTHORIZATION FOR �<� C'..1 � �--y,/ � VVASTEWATF.R _ _ SYSTF.M CONSTRUCTION Tax Office PIN:# AUTHORIZATION NO: �Q���� A Road Name: �7� �'�'����� �fZip: '��'`�`� **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by.the Davie County Environmental Health Section prior to issuance of any Building Perrnit�.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. • (In complianceswith Article.l l of G.�S�Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ' J �, ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION � �-�'� .���`�-�.r''f �� �+� `.�� IS VALID FOR A PERIOD OF FIVE YEARS.. ���NVIRONM N'�A"t^'tt. SPE�IA�,ST- DATEISSI.ED . �- RESIDENTIAL SPECIFICATION:BUILDING TYPE ���}t #BEDROOMS «� #BATHS -� #OCCUPANTS � GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILI7'Y TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE�1'es or No LOT SIZE ��n^��PE WATER SUPPLY��V DESIGN WASTEWATER FLOW(GPD)��� NEW SITE REPAIR SITE � ,� M � ' SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ^�� ROCK DEPTH ��,, LINEAR Ff. '"'�� OTHER ( I1�S���-) �UTI�`� �.'VlC. � nl.�};^C�1�n�U�L�►^�Vnl•-�iG � REQUIRED SITE MODIFICAT[ONS/CONDITIONS:���!��'L � �^��(�"'`-� �%� ��, 1 ���•..i�}wL!► , (L�+�./ �+f=��,r•• Ntvc� IMPROVEMENT PERMIT LAYOUT r ��^---�.��:� ' =�(:�IE.c.lt. T�u� �i f , •. v• �. T9,.�,.�c, ur �>c.��� ►�� : .� ^r �. .-�` 1�� �1.��"C`.�!`�- i..r�1�.�j:2G 'P � .�. 1 -��, ��� � v • '_`L�+.�'f 1JY�i:`f C 1,.�'J G �j -� �ii+� YV"`a�W . �; y�, �`,: �-t:..-1� � 1�L-CT ��'-�' ��-� � � � f �•1 ���iA/�c�'K��tT�Ji.�l l,� � �,�.A.:—..r���us,:.-�� "�1 i c�`�^}1r___._ , ��J��a � ��� � . �? '---�� �1� : � . �� � .�� s .�.�-- -�----�. FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BEI'WEEN 830-9:30 A.M.ON T�E DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. � OPERATION PERMIT � � SYSTEM INSTALLED BY: �l:��C,,I�LS �[�....��c ;i � r .. , C ��,J � , , t ' AUTHORIZATION NO. �`''�� OPERATION PERMI Y: DATE: � �� �' *'THE ISSUANCE OF THIS OPERATlON PERMIT SHALL INDICATE THAT THE M DESCRIBE OVE HAS BEEN INSTALLED IN COMPLIANCE W1TH ARTICLE 11 OF G.S.CHAP'fER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTTON SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. �o���,�> ��=�- 3 '� y . �n v � ,5'o � 8' :���:� r '. .- �� .. . . .. ..: . e. -. ,.�: __.`s���:,,,,z_ �z � ...�-� . ., - . ,. _,.,....1..=- ,_ _ ��,-_, _..- . . :.:1:....__.,,.,�. .� .��.- -- �.`+� , ���� '-, .. -_ . .<ir- " , ' .. �.�`., �� ` .,�.k�.. � ,�}+� :� , . . . , "_ �-_:_-. �:_ „ <_ � ., . _-, .. � � y -DAVIE COTJNTY HEALTH �= r , , _ _. , , "` `_ `DEPARTIV�ENT., _ �i=- . ,, - • -- :�,. .:.� __ . - �a`=^= �+ Environmental Health Section � : '(�7 ._. PO Box 848%L10 Hospital Street . - '` - � . - -- _ r .� . .� . . , ��=�; Mocksville,NC 27028 ' - ' . Phone: (336)751-8760 �. . J.�.. . " ' . �. �; ON-SITE WASTEWATER CERTIFICATION FOR DWELLING � �� ;< : (Check One) REPLACEMENT� -� REMODELING ❑ RECONNECTION o ; . � . y��{ ( �i Name: �Ca 1�"� .f V 10�1 r'� ' Phone Number:f 33 G� �9� 'a�C? I7 (Home) �'-� �Mailing Address: 7 �a1 ;_ C' �33�C� 7���-��� ���'(Work) . 45� ,`; -�- N G `�'7n.S'S' , � � .i... . . J+;. . I L �' ' , i Detailed Directions To Site: l�u� ro OG�SUi�{ "p'' � d :`,. �"H i� � � ��' �� i ..:..�,,. 1�6� �G,�+,c� � ,. o as � �� �cti r+� a� -�s � b / PA �s��' � a O f //t� ? ��Cf�' �j� /�� o { /� Property Address: �`7 7' ��2er�cJ�i J �a ' � � ... . ._` . ,. ' - . . . . . . .. . ,. _ . � �- � TaYi:. : .� .._ . , ,.. . . .. . -. . . . . _. .... . _... _ . . . .> . ^ ,dC " -Please��FilI Iri T1ie�ollowing�Information`Aboufi�The'Existing Dwelling .�� •���- � -•-�_ . .� .°= , - -�- y�e- /�IA,eti' �lao/'G _ T Of Dwellin �/ Su/ Name System Installed Under: ype g: Date System Installed(Month/Day/Yeaz): s ZL- 9Z Number Of Bedrooms: Z Number Of People: Z � !K Is The Dwelling Currently Vacant? Yes❑ No� If Yes,For�How Long? , Any Known Problems?Yes 9' No❑ If Yes.Explain: � .���� �t� /�'��� /Y1 ti� � �f'y.s h P C''o ,, . � s° . . ' �y Please Fill In The Following Information�About The New Dwelling. . . . _ _. . . . . -. yy. . . - 1 � . . . . . TypezOf Dwelling: -w: i J, '`Number Of Bedrooms: 3 Number Of People: ,.,:�,;. � ` ��-Os=oS' Requested By: � Date Requested: , (Signature) ; For Environmental Health Office iJse Only ' ; ..Y.:'.' � :-:��' ..J.��: 1 . � ._.;: __. 5-..- .,;',r - s. j Apprdved�Disapproved? - ��.��' - - '"� - -- � �,,, ;�;���_ � � r . -- - Comments: �`�t�U� Y.�'.LS�12. r�t�+.-� �- '� ��_._or,-� �.�J�-�L�..� -5�7�----- t�" �.1���► �-/.�,��.slQ,� -� q.::-�� � .-'q' _ . . Environmental Health Specialist Date !� ! '� r ""The signing of this form by the E ironmental Health S is in o way intended,nor should be taken as a � � guarantee(extended'or limited t the on-site wastewater system will function properly for any given period of time. ' Payment: Cash❑ Checic� -,Money Order 0 # ��� S �Amo r $ l� d �� Date: '"'"p s ; . . ,• ; - Paid By: -_ Received By: ` "� ' : :: � ; Account #: -.�- � � � Invoice #: - � � � �•- : . ....�..--Nn �. .T,�-�'W'T/"4..w f. .«. � .� .-: v -:.. . : .. .. .. r•�<:T 'y�'°.'�l .0 e . .. :. -. . � �. .�a..�� .w.,�.t��.. y_ _ ... ,�I� ��� ; � DAV'fE COUNTY HEALTH DEPARTMENT G�'"� � . . � Q� ��� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems �� � Permit Number Namel�if./�,�iaiC, a=YY , �:r��-;��t'�������ate �'����!`..� ND � � • _ - Location ���'—;;�°'G' .��'�'c` .�����.e���.�5'� .�'�,L,�'�=`Sf". r,:'� �G;� � � %` � ,���-.�1� �/ �. ��-- � Subdivision Name Lot No. Sec. or Block No. Lot Size �i9i~ House Mobile Home � Business � Speculation No. Bedrooms �.No. Baths� No. in Family�__ Garbage Disposal YES ❑ NO p�' Specifications for System: % • Auto Dish Washer YES � NO ❑ ;y 4 �lD���/�'%��- --. ;� ► Auto Wash Ma:hine YES [rj NO ❑ Type Water Supply �// --- ���.rrl 3��,�' �,/�„�1�- ./ `This.permit Void if sewage system described below is not installed within 5 years from date of issue. . This.permit is subject to revocation if site plans or the intended use change. .�'��. .�t,.�,.�., �f� \ �`'�� � ......_....M_._.__.,_....v..� o ! � s ; r .,,-T.....-----..�...�..,.,._..,....._,.�,.,� � : Improvements permit by _�'�_._._�-/� '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 !,\��=�-� �� ���-"'���~- _ _�_ . � ..... _�_. � � �. � i� t`i� ,�` � _ � �� . � '� �;, r _..., �\�� ,;,a...� � Certificate of Completion 1�� � -a-_a"ti�'��- Date �'�� ���- "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 shatl in NO way be taken as a guarantee that the system will function � caticfar.tnrilv fnr anv nivan narinri nf.tima � ' :. �, y Iw�F,n.ca.y� -�"= v� .Y'.. ?� � 1g rfLj-f�`�,� �. fp • � _ L� a. ��Y 1'P� b� F,��1 Lr�• 1 .tln� i� � �� c. aF- -r' ?!-, ,�rri` x" ' vi� `��` ? i? ' Nic ak. 'S d .� �?xSh,...ys i '=� r �`g. � r , F # � �s ,�:y ''�=g ��, �+ ��' � � 5 A p.Y �{ 7� � .. q, � � � E �dy,J ' r �.,'.. � �Y+C.3��. ( .y� . . I�i_:..` �,.,�,.�y�� _. ,�4F �� r � � j` . . . ,< Y �ti',�1T, . i ��� � . �, 4 �`` * > '��� -�' "'�. � � f `t � : �.'R � Z ' 't'k'�''� . 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