367 Sheffield Rd AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT � *• o•
05.60
Environmental Health Section PROPERTY INFORMATION
Termittee' � �' �. to 1S' P.O.Box 848
Name: Mocksville,NC 27028 Subdivision Name:
/ Phone#:704-634-8760
Directions to property: 17��J - tel Section: Lot:.
AUTHORIZATION FOR
WASTEWATER
- -
� SYSTEM CONSTRUCTION. Tax Office PIN;# t
•C J: ` �cs Road Name: e ' Zip;MQ 7
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building'Pennii , his 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 130AI,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�„ � ^��» �d'�� '��G► IS VALID FOR A PERIOD OF FIVE YEARS.,
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
AY y ArM T ..k1:ei t F..•'� y.ley {-.'S . .JM;'� Iv k A4r.i ' .`-,. - 1 ,Ltd A 0. • r - - „ 'i
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
�1`erthitt
Subdivision Name.
Directions to property: ��� s.� �+ �r�a Section: Lot:
IMPROVEMENT
PERMIT _
Tax Office PIN:#
" �'" ►Y, `�. x `t. Road Name: Zip t'`�`
**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)
( �z ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
' -.s. • -� ' " 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 aUSa.#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes of o
s .
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFr #SEATS INDUSTRIAL WASTE:Yes or No
i
LOT SIZES • TYPE WATER SUPPLY cM DESIGN WASTEWATER FLOW(GPD) 1.20 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZED C GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH j LINEAR Fr.
6 k �
OTHER `
REQUIRED SITE MODIFICATIONSXONDITIONS~-- t,)e U O 0 T Q- !J S 1 U e W Q
C.m,
IMPROVEMENT PERMIT LAYOUT 2
o a �
O� _
s
3
**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 QQ`
SYSTEM INSTALLED BY:
0 w nl
7
AUTHORIZATION NO.O D OPERATION PERMIT BY: C 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)
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F;
DAVIE COUNTY HEALTH DEPARTMENT
1{
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
grmitt e' r•,. r.
--Name: Subdivision Name:
Directions to property: l•' ;' �, Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# -
r w `ti Road Name.
**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
" » :w•. "M�` , y+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 I SN #BEDROOMS 1 #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or670)
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT / #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZES TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) IQ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE I p0 n GAL. PUMP TANK GAL. TRENCH WIDTH - + ROCK DEPTH _ LINEAR Fr.
I
ti r
OTHER '
REQUIRED SITE MODIFICATIONS/CONDITIONS: O t► 1 to c? 1.) e N)F \V W Py
u C_ C
IMPROVEMENT PERMIT LAYOUT a J
`gyp -
f x
**CONTACT A REPRESENTATIVE OF THE DAME COUNTY HEALTH DEPARTMENT FO1��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)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY: ✓o
-�, ar7. oto
1
AUTHORIZATION NO.0 5 6 C) 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 SYST M%WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
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.. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
-�- APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
- I
NAME d-�1 G Z-)1 - PHONE NUMBER
ADDRESS �O l �h� i C� �. rid- - SUBDIVISION NAME
i! C k AIC-. 'A I Do'g'F LOT#
DIRECTIONS TO SITE
�i)'L f�- C�`�e � Sal eT7-i���- �a►�k. � ������ �1 d�-(S�.
DATE SYSTEM INSTALLED ? NAME SYSTEM INSTALLED UNDER L 10 Y11 A 0/YheDI0. �
TYPE FACILITY 0 NUMBER BEDROOMS 1 NUMBER PEOPLE SERVED �—
TYPE WATER SUPPLY e I SPECIFY PROBLEM OCCURRING 23,4ck "(p /Y►
DATE REQUESTED D o� to INFORMATION TAKEN BY �G�f/ k uS
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am rreesponsibl for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT A:7
Rev.1193