P1251 Richie Rd AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT
1251
'Environmental Health Section PROPERTY INFORMATION
Permi;eee s, j P.O.Box 848
Name: ®/l�/1� �,�/ ,Tf�, Mocksville,NC 27028 Subdivision Name:
JPhone#:704-634-8760
Directions to property: ri `rf Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#SYSTEM CONSTRUCTION - -
Road me Zip:-G
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen-nits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
"' `f ' i"• IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SP CIALIST DATE ISSUED
rx`�. ` ' ''�i'�''�+rt N''`<' $.,K,.µ�:Y �..,.�• t>._:.i z ;d-f i.r+ � •J�{- L � ... ,.. _: ',: ;:tr,r .. ,. � '.
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125 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permi
Name: Subdivision Name:
Directions to prsperty: � ''` ' Section: Lot:
IMPROVEMENY*
PERMIT Tax Office PIN.# • - •A
Road a & Ak
'' 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 the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
r,
'' .✓ ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
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 f)� #BEDROOMS #BATHS #OCCUPANTS—/--GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY–AL11Z DESIGN WASTEWATER FLOW(GPD)` NEW SITE REPAIR SITE
` A/
SYSTEM SPECIFICATIONS: TANK SIZE �D GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.DC7
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r
**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(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
W
AUTHORIZATION NO. J' OPERATION PERMIT BY: �i DATE.,S
**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 05/96(Revised)
i . ... 'f a t.. ♦ az \ l. tai�a x wE ., ... ���/
1L r DAVIE COUNTY HEALTH DEPARTMENT
'
114IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Perm1=L s
Name: Subdivision Name:
Directions to property: *,: Section: Lot:
IMPROVEMENT'
PERMIT Tax Offic� N:#__�,�J•
Roadm a ' ""r ZiiD: 4 n�r�
**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 the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
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 -'? #BATHS #OCCUPANTS_ GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
\
LOT SIZE, TYPE WATER SUPPLY. DESIGN WASTEWATER FLOW(GPD)`-PU-e NEW SITE REPAIR SITE '
,.,.., A/
SYSTEM SPECIFICATIONS: TANK SIZE �D GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH:55 LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: n
IMPROVEMENT PERMIT LAYOUT
w
"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(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
uJ ��
AUTHORIZATION NO.2_f_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 05/96(Revised)
i �
422
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
YVORKSHEECT/FOR SEPTIC SYSTEM REPAIR PERMIT
NAME r �s Gid PHONE NUMBER
ADDRESS 6 SUBDIVISION NAME
n, SU IVIS ON LOT#
DIRECTIONS TO SITE /v ' Ni"
e � -�
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
I
DATE REQUESTED JNFORMATION TAKEN BY