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768 Redland Rd /--�'`,.j _— . . .. ... -n Q • Q� Pet�nittee's' ��1 DAVIE C4UNTY HEALTH DEPARTMENT ��1�' � Name:- �h nvironmental Health Section PROPERTY IIVFORN(�� / �.' P.O.Box 848 ( Direcf n to property: hlocksville,NC 2702$ Subdivision Name: �� q � Phone#:336-751-8760 � `/'��L�i'�/, !(/�� Section: Lot: ' AUTHORIZATION FOK R'ASTEWATER . Tax Offic P N:# - SYSTF,M CONSTRUCTION ��p �� 002641 ° AUTHORIZATION NO: A Road Name: Zip��u� **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior to issuance of any Building Pernuts.This Fomi/Authorization Number should be presented to the Davie County Building Inspections Office when applyina for Building Permits. (ln com liance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � � ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION �" ��G�i��(� IS VAL1D FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUE�r � . � ;- -�-., , _ __ t..:. . , r t � ;y�ry�_ ,_�...,• . ..ti� . , �P...,_.t' - .t � .t,: ''ia.:3 "�'� . ., � � _�� .� �\N,A� . .+...aG�' . . . . . � . .. . . � Pe�{ittee s"'1 / � � DAVIE COUNTY HEALTH DEPARTMENT / O� f Name:�`� Y�� -�/v!' �`( Environmental Health Se�tion 'PROPERTY IN M7�-7j ' !y Q� /} _/ � P.O. Box 848 �� Du�ecf n �to property: /�l, �J/',/il.�/�� Mocksville,NC 27028 Subdivision Name: . Phone#:336-751-8760 �� Section: Lot: . 'w'- ' AUTHORIZATION FOR ��_ �` :��. , WASTEWATER . --- SYSTF,M CONSTRUCTION Tax Office PIN:# - - �, ,, �f , AUTHORIZATION NO: O O L G� � A Ko��N�P��1 � Zip� ' **NOTE**This Authorization for Wastewater System Conswction 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 applyina for Building Permits. (In corr��liance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section�:1900 Sewage Treatment and Disposal Systems) / /� ��,/ //��`�� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IU�E� � IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUE ,, RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS��#BATHS�_#OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY 1'YPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No LO't$IZE TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD) � v NEW SITE REPAIR SITE � / ,/J �-5� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH,�� ROCK DEPTH�I.INEAR FI'.�1 v OTHER � � ��F/(/ / ' C�rA � p� ,�DJ�rt C'�� `I� REQUIRED SiTE MODIFICATIONS/CONDITIONS: IMPROVEMENT E IT LAYOUT / n� . A;�¢ �Q 7 { �p Vtr�� '� �, � �r��J`n!� P s� � i,,n�� ;n QCp� . /6' �/f� � , I, e �-'� ��;�� ;,�1 �� bo FOR FINAL INSPECfION OF THIS SYSTEM PLEASE CALL BECWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. � OPERATION PERMIT � � SYSTEM INSTALLED BY: � / •O � �� ✓ � � Q � �O �' � �� . �� AUTHORIZATION NO.��_�—�—OPERATION PERMIT BY. DATE: � "THE ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE ' WITH ARTICLE 11 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND,DISPOSAL SYSTEMS".BUT SHALL IN�IVO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. nC[�[u ozroz pte�u�a� : w, , : , � _ �. . . . DAVIE C .. ,. - n . , 5 - ,^ � . _�* . . ; , , ,^, .,, �, , - , . . . . Pe�mittee s• � �" � OUNTY HEALTH DEPARTMENT � � 11 , � %rNam�:"� �'/��''%''T ��''" � Environmental Health Seetion PROPERTY IN ORM� :- ... �y �,-- , ' ' ,,,'' P.O.Box 848 Directions to property: �''t; t` '` � '�r 'f' '` Mocksville,NC 27028 Subdivision Name: �� , ;,,.'�.- , i ��- Phone#:336-751-8760 �� ..�/,'yE;� , �1.l Section: Lot: "'_-,�v;;. ' AUTHORIZATION FOR � � : �� WASTEWATER Tax Office PIN:# - " SYSTF,M CONSTRUCTION - - 0 a 2�41 '��^� ,��z�:'�,�,��r�'�.1 AUTHORIZATION NO: t� Road Name: Zip: % **NOTE**This Authorization for Wastewater System Construction MUST BE ISSU��by the Davie County 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 applyina for Building Permits. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section�1900 Sewage Treatment and Disposal Systems) '�` ' ***NOTIC�***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �"�)' '��` �` ``��f � ��,!t t � :-Y`� ; IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RFSIDENTIAL SPECIFICATION:BUILDING TYPE_� #BEUROOMS � #BATHS,_,�_#OCCUPANTS_�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFlCATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No . LOT SIZE TYPE WATER SUPPLY �O DESIGN WASTEWATER FLOW(GPD) �� NEW SITE REPAIR SITE ` r �:: / � SYSTEM SPECIFICATIQNS: TANK SIZE GAL. PUMP TANK G �`TIjEI�CH WIDTH �'�� ROCK DEPTH '� ��LINEAR Ff.�� ` ,/ / , r OTHER �� /�Iv� ��/""�:!("��`� ��5/'"�!i REQUIRED SITE MODIF7CATTONS/CONDITIONS: IMPROVEMENT P��R�tIT LAYOUT �� '�� (� �Q� � `n ��r�� a ( �� ` C ��'z�' «�l�� { J� \1 �,��17:/ -;•� : Q��1 �6� �'T/4 / � 1,. � h-�y1 __..._..�- �. ., � ��;�i ��`� ( F fi i��~ ` � . I.i'� : ' � . � � � FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BECWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. � OPERA'I70N PERMIT �� /i � � Q SYSTEM INSTALLED BY: , a �� Vv_ � , : J �: � � � � � � \ �'` � � � . � � � 1 ��/� . �� /•� � AUTHORIZATION NO.��'��i-OPERATION PERMIT BY. DATE. Y� �. ••TI�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE� WITH ARTICLE I 1 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTO$ILY FOR ANY GIVEN PERIOD OF TIME. ncNn oznoz(�te�ua� . , . .-, s ,-> ' ' .. . -t.•• -H . .- � F.I+ 5 ."..... . -.--_. -.. . - . S'_ . ... ,. .. . .. . �}�;� ^" � T �1�' '2 Pecti�i�te�'s` , � DAVIE COUNTY HEALTH DEPARTMENT '` i�`� • �' �,` �,� � ,.� { � f�Nun�:'� t��t`-r� `'� ' Environmental Health SeStion PROPERTY IN O�tM�I�N .. ` a., ,._ P.O. Box 848 �Directions to pmperty: ry ° ��;.'' Mocksville,NC�27028�- ':` Subdivision Name: r'',' r� ` Phone#:336-751-8760 ` � ' - Section: Lot: ^� - ' AUTHORIZATION FOK ' - • , . • WASTEWATER Tax Office PIN:# • ' SYSTF,M CbNSTRUCTION - - r� 0 02�� ri'"'�r�! i {a /n ? ,� AUTHORIZATION NO: A Road Name. f 7.� � . Zip; --r-�ir1 **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUEb by the Davie Countv Environmental Health Section prior to issuance of any Building Pemiits.This Forni/Authorization Number should be presented to the Davie Counry Building Inspections Office when applyina for Building Permits. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) - , ,,, � ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION �- � � • • � `� .�%1'; ' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS .�- #BATHS�_#OCCUPANTS '� GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No /�Y .� LOT SIZE TYPE WATER SUPPLY ` L DESIGN WASTEWATER FLOW(GPD) �1/� NEW SITE REPAIR SITE � ` f�� / � d--!. SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GqL. -TRENCH WIDTH ��-� ROCK DEPTH �'�.-LINEAR FT. -� '` _ / �....r....,. � OTNER f"�r �" —1 .�/ti/�%� � G;%i r` ,��';y��-,i','r ✓/'•��.F'�'// �j c��t '...�.�l�/', /:• REQUIRED SITE MODIFICATIONS/CONDITIONS: ` � IMPROVEMENT P�RMIT LAYOUT � �;� ' ��' ��P � I � , �'�� t �� , � ��;:' �-�,�� f l�,�•. � s t� � .7 s �.`; ;1 � � /G� l . ' ' " �� , `+ 1-- 1 ,r�f l-� . _�� ' !:a L ,{ F � �� . �� .� , J�J� 4�. �, � �� FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BECWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT � f• i —G' � SYSTEM INSTALLED BY: '-(�d�� l�/ 7 •,� � _ �� ,--r JG�/!�� : � � . � �_ � , �. � � � � ' � C� - � �. ,� % � ' . r /� � AUTHORIZATION NO. �`�%`� OPERATION PERMIT BY: �~// DATE: �� r �. C � *fTHE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S.CHAP'TER 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) _ . � ,� . � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ' APPUCATION FOR IMPROVEMENT PERMIT(REPAIR) NAME � 6 � � : �! PHONE NUMBER ADDRESS_ __ �6��`P/�''l i\[ SUBDIVISION NAME T��✓ �l� LOT # DIRECTIONS TO SITE �� yJ�L°��,� �� /9R°//�%��/�f a�, �� 'L � DATE SYSTEM INSTALLED �S �� NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �'Y� ri ,� DATE REQUESTED INFORMATION TAKEN BY �� This is to wrtify that th�info►mation provided is eorcect to the best of my knowledae, fhat 1 eratand 1 �sponsibie for all charpes i rcsd hom thia application. SIGNATURE OF OWNER OR AUTHORIZED AGENT R.,,.,/93 . � ��_:., . °Q.4'j: _.i� . - -. , . . - _� . .� . . .. . . ' 4�} ,'1-.�• v�-;� f ` �' � `� �.�y 'f.� �-,�,_,; ay:,= "^, s .�.� 'i':��h; . , . � . - .: . � "_ ""P t' �0�� , .,9 . , ... ..� _ .- '= . ..�.: . ". .... . '. - . . � .� . y �� / . . � _ � , i ,� ��DAVIE COUNTY HEALTH DEPARTMENT � - ' ,.�� IMPROVEMENT AND OPERATION PERMITS:. PROPERTY INFORMATION �' Permittee' � " t , fi: � , N Y .Name: 3 � , �, Subdivision Name: � /� ,�j f/ , Directions to property: j��5 :!/='7 r�'r f.�I��l� Section: Lot: �?� ' IMPROVEMENT ' - �'"1"/�i;•''��%/'(� s�� . PERIVIIT Tax Office PIN:# - , �G ' Road Name: Zip: Z7 , **NOTE**This Improvement Permit DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system.An AU'I'HOWZATTON FOR WASTEWATF.R SYSTEM CONSTRUCTTON must be obtained from this Department prior to the I ' construc6on/'u�stallation of a system or the issuance of a building pernut. , ' (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) : � '' r "`**NOTICE***TI-QS PERMIT IS SUBJECT TO REVOCATION IF SITE -�`i`�,�� '�- ��, �I,, : PLANS OR Tf�INTENDED USE CHANGE.YOUR WASTEWATER . , �� SYSTEM CONTRACTOR MUST SEE Tf�S PERNIIT BEFORE - ENVIRONME�HEALTH S CIALIST: DATE ISSUED INSTALLING Tf�SYSTEM. : " , RESIDEIVTIAL SPECIFICATION:BUILDING TYPE,....� #BEDROOMS�?#BATHS �OCCUPANfS c� GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION:.FACILTTY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WAS1'E:Yes or No ' � _ " LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) ` NEW SITE � REPAIR SITE 7� // �� ; ' SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH��' ROCK DEPTH �� LTNEAR Ff�:; , OTHER . REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENTPERMITLAYOUT.��7p�}DVED EFFLLIENT FIL � �RISER(S) IF 6" BEl_QW FINJIS�I�D 6F2�DE� � �� '. S�' I� : :, � � /,� � . . �� *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.1'ELEPHONE#IS(��f E��bx (33b)751-876k3 ' OPERATION PERMTT SYSTEM INSTALLED BY:��.�G� SQ,�!/r✓✓! � ` /S?7��Grl�� J� ' � �� AUTHORIZATION NO. ��OPERATION PERMIT BY: DATE: -1—� *•THE ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE THAT Tf�SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE: WTTH ARTICLE 11 OF G.S.CHAPTER 130A,SECI'ION.1900"SEWAGE TREAT'MENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A , GUARANTEE THAT THE SYSTEM WILL FUNCfION SATISFAGTORILY FOR ANY.GIVEN PERIOD OF TIME. DCHD OSN6(Revised) ..�7'�'} '4�.f'l�u✓i 'z-e�1'��•�'�1 �w W...'srotYi:w, ..�,., f r �y1 y� .�. �.. z: ...�-��_ r- � t ��- M� $ 4 '1; .t:,• x` �{;�` '+` Z � i..,� .c+�-ri A a `� d'•e" �s.* � _ {'� ,. �, , � � , �>d��y�. .�O-Uj �. ��, ��,�1�°�:� ` i ; ;;� ;,,�DAVIE COUNTY HEALTH DEPARTMENT �` �„ TMPROVEMEI�T AND OPERATION PERMITS PROPERTY INFORMATION � s�f »�F�r tie' '� ��;. V�+J , I / r r� � �� ' ' �` ; .. .�-., , � ' :ame,' j�'t �'� `.��x _� � ;;y: �t Subdivision Name: 'r' Directions to.propert �h�• �� • .�� '�• �> � Section: Lot: �'• . ` y- `., �� Il1�PROVEMENT ; �--'" ,, �,;',f< � . ; �,` PERMTl' ' Ta�c Office PIN:# - - �--- ; Road Name• � Zip: �7Q T� G -�� *NOTE**This Improvement Pemut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An �'--=.,,, -. ;�AiTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUC'TION must be obtained from this Department prior to the �� construcUon/installation of a system or the issuance of a building pernut. _ (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Sec6on.1900 Sewage Treatment and Disposal Systems) ! ;, �' ,� � , ***NOTTCE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE � � I��.• ;�`�; ti i:'}yd ti �'�':��;`r�?' ,.,/�/ ,C"�� PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENT A�.HEALTH SP�CIALIST DATE ISSUED , SYSTEM CONTRACTOR MUST SEE TI�QS PERMIT BEFORE ; • INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICAT'ION:BUILDING 1'YPE�_ #BEDROOMS �' #BATHS u��..#OCCUPANTS�/„�GARBAGE DISPOSAL:Yes or�No COMMERCIAL SPECIFICATION: FACILII'Y TYPE #PEOPLE #PEOPLF/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No . ' .. . � . " . . . . . . . . . �. � ' . . . ' .. � 5 . :.. • • � . . ' . . . . ._ . . . � :. .. •"..-'s � LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) ' NEW SITE REPAIR SITE - �" , /! �� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�r' ROCK DEPTH �� LINEAR FT� i �. ' OTHER i REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENTPERMTf LAYOUT�1FAAr^ROUEA E.FFIrUEIUT FIL � �RIS�R tS) IF b" �E�Obi FINISl�EA GRAD�� . . ' }. ;`; _ !✓"� � '. ' . . _ , , {'� � /� � _ �� f _ � � t f, ��; + , ,. � . . . . . ... � r � . . ��S+.�Y� . . .. . � � . . . . I .. . , . . N. � �.�' ' . � ... � a **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTTON OF THIS SYSTEM BETWEEN 8:30-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLAT'ION.TELEPHONE#ISj��d��M ' - : (33b)?�1-67f��f : - OPERATION PERMIT 'n ^� . . SYSTEM INSTALLED BY:,�,[��a�2?�ID'/1 VJ.Gl��✓1�7 � �!�r� �.S��'� . • � : . L� 1 • �/ ; AUTHORIZATION NO.�q /�OPERATION PERMIT BY: DATE: �/ **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT Tf�SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE � WITH ARTICLE 11 OF G.S.CHAP1'ER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A '� GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96(Revised) � _. , _. _...., . ��. . ��M�+� . ' . ' •..... 4 .. � .. .. � . . v -..��v . . ..., , . �:.:. . � ,, . . � . . I . � . ... . .. ... ...�... ... .. :.... __� p�_ �J ti � . � . . .. ��_ � ..s ' v � . . .. - ___—'..�. �..� �Yss.._. . . . '' � DAVIE COUNN ENVIRONMENTAL HEALTH SECTION � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) � � NAME q-n � �-f-/, PHONE NUMBER � � ADDRESS_7(��tina2 �,1 _ SUBDIVISION NAME ` � �J Q�� LOT# � DIRECTIONS TO SITE '� �) DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED � TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING � � DATE REQUESTED INFORMATION TAKEN BY � This is to certify thnt the information provided is corceet to the best of my knowledge,and that I underetand I am responsible for all charpes incuned from this appiication. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93