152 Speaks Rd \.fiYt .�'�"_ t '.f S .T- r1: ` �:i� �:-�. i-5� h�+",._.r:f f7e��`-�f-`..v� ..�.:. i.� Y': .-. � ...'-• 1' �T..`�:�.,.t...v....:.. - , .
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' 'Pen►Wiee's -� ' �� ' D VI CO NTY HEALTH DEPARTMENT '
'- .Name:--� �`.•�-` � `� '����:.�� _ ! '��vironmental Health Section PROPERTY INFORIVIATION `
-- �C� '1b. � ������ '� P.O. Box 848
"Dire�tions to property�.� ��- ��ih��={w Mocksville.NC 27028 Subdivision Name:
/ . � �� � .,� �1� � Phone#:336-751-8760
� Section: Lot:
.. , � AUTHORIZATION FOR
�� �,�."� �� .�-_ WASTEWATER Tax Office PIN:# _
, SYSTF.M CONSTRUC7'ION
�y )� /'� ,,.
AUTHORIZATION NO: � 1 ��� A . Road Naht��.� ``� �� ��Zip.�� �
**NOTE**This Authorization for Wastewater System Consuuction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permit�.This Form/Authorization Number should be presented to the Davie County Building Inspections -
Office when applyin�,for Building Permits. `
(ln compliance witt�Article i�1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems).
i;;/, ,
% l� '"—"�� p� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION'
,r� �';% �. ! �' , IS VALID FOR A PERIOD OF FIVE YEAR5.
IR ENTk ALTH SPECIA SI' DA E 1 SUED
�� � � '� �;' � ,..
RESIDENTIAL SPECIFICATION:BUI DING TYPE.��#BEDROOMS �"'�#BATHS�#G��S�GARBAGE DISPOSAL:.Ye r No
� .
COMMERCIAL SPECIFlCA'T�ON: FACILI7'Y TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE '�' �(�TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD)�-1 c � � NEW SITE � REPAIR SiTE ��
,� ` �� : ' _
SYSTEM SPECIFICATIONS: TANK SIZE� AL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH�� LINEAR Ff._.�A�
- . OTHER S /.%��� ��QtJ�Zd� LiC/X�
REQUIRED SI'TE ODIFICATI NS/ ND1TI0 : ` ' "�� A �
d���
IMPROVEMENT ERM1T LA O � � � V� �- ,
-,� � �
� — �-- � �O�5�: � � _ l ,
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•*CONTACT A REPRESENTATIVE OF THE AVIE COUNTY HEALTH DE ARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 830-9:30 A.M.OR 1:00- L•30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT t � �
SYSTEM INSTALLED BY: r �
_ : � �y s�"
�
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. � ��� . �
� _
; . . .
A[JTHORIZATION NO.r/,/,C���PERATION PERMIT BY: C�'�'`�l DATE: �' `
••THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTfH ARTICLE I 1 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 07/02(Revised) .
, ' ��st�
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_ .
- � • DAVIE COUNTY HEALTH DEPARTMENT D � � /�
Environmental Health Section j L � � �'
� PO Box 848/L10 Hospital Street �A�11
- Mocksville,NC 27028 _ 6 20�� s!
�,�,.� � Phone: (336)751-8760 r
" . ElVV/RON47ENrA�y�Ty.
"; ON-SITE WASTEWATER CERTIFICATION FOR D ��iFr,a�
JNIY
�p. (Check One) REPLACEMENT❑ REMODELING ❑ RECONNECT
;;
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Name:�: ti..��L� ) u S i-t,�� Phone Number: `�(Home)
t:; ��y Mailing Address: I.3 Z �v-e�-K-S �d . � `' (Work)
� � n ' ' .
. ' �-�-o� �ti c.-�. _
, : Detailed Directions To Site: 1 �--�' ti .�S e w � . L „����„I b.�J
. l • � r�,�,��.� o� S -e L S�— a.�� o ,✓
� � �.�- ��
Property Address: -�-¢-�S �°t' '
;; .
Please Fill In The Following Information About The Existing Dwelling.
� ?
Name System Installed Under: " Type Of Dwelling:
L "',n,-�, {�
Date System Installed(Month/Day/Yeaz): T�e��c�-d 4r� Number Of Bedrooms:3 Number Of People: :r
Is The Dwelling Currently Vacant? Yes� No�1�Yes,For How Long?
Any Known Problems?Yes� No mil�Yes,Explain:
$� d �.�-�-� � o ;.� , .
Please FiII In The Following Information About The New Dwelling. �I 6���
} Q� 1 `t- � ''
Type Of Dwelling: I 1,� "`3-�- Number Of Bedrooms: Number Of People:
Requested By: Date Requested: �/L /`a 3
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑ �
Comments: l�l�'l ` I�l 4F. ���h., �T ( a �j j O l�t�"l�� �`� t�^-`.
:
. ' ;'
Environmental Health Specialist r Date -3
'"�The signing of thi.s form by the Environmental Health Staff is in no way inten ,nor should be taken as a
guazantee(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: Received By:
Account #: � Invoice #:
� , r 1. � . � . . . ' .
. � . ' . . � . � � . � . . . .
y � � / � . � � . .
� APPI�CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& � � � � �I �
, Davie County Health Department �
, Environmenta/Hea/th Section ��� �
P.o. sox 848/210 xospital street t JA�) - 6 2003
Mocksville, NC 27028
(336)751-8760
ENVIRONMENTAL HfALTH
***II�ORTANT*** THIS APPLICATION CANNOT SE PROCESSED UNLESS ALL QUI`T2Eb=-J"
INFOFit�TION IS PROVIDED. Refer to the INFOEt1�aTION BIJI�LETIN for instructions.
1. Name to be Billed \ � Contact Person c�-�PYI�,
Mailinq Address Home Phone 1�y�0 'Qy�— c�0��
City/state/zZP �V������ Business Phone �T��e,
2. Name on Permit/ATC if Dif£erent than Above
Mailiaq Aaaress cit3r/state/zip
3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both
a. system to service: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: g People �_ � Bedrooms L, # Bathrooms p2�l a
�J,Dishxasher U Garbage Disposal �Washing Machine ❑ Basement/Plumbing �YBasement/No Pl�bing
6. If Susiness/Industsy/Other: Specify type # People # Sinks
M Commodes � Sho�ers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage �galions per day)
7. T�Pe of water supply: ❑ County/Ci.ty �Well ❑ Community
e, .Do you anticipatc additions or expansions of the facility this system is intended to servc? �Yes ❑No
If yes,what type? ' � � Q., C,
� .
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the clieut with THIS APPLICATION.
Property Dimensions: �. <)�(� QU��5 WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax OtTice PI1�1: #���(��-� ` ��- r� 1 �-.
Property Address: Road Name � t� � — \r1 (lQ.S
City/Zip 1 C�'�(�'��a�Ci�9 V`��1' (Srl ��� �
If in a Subdivision provide information,as follows:
l� M�i
—r--
Name: �
Section: Block: Lot: Date Property Flagged: �— � � ��
T6is is to certify that the information provided is correct to the 6est of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information `
submitted in this application is falsified or changed I,also,understand that I am responsible fot al!charges i�rcurred from
Jhis application. I,hereby,give consent to the Authorized Representative of the Dav'e County Health De�artment
to eater upon above describcd property located in Davie County and owned by C�Ti 1� � �YY�� Cli,r �U.�'QSl
to conduct all testing procedures as necessary to determine the site suitability.
DATE lI�D I O� • SIGNATU .
�—
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN nclude atl o the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
���.� � Client Notification Date:
\S G��«��,n��
o�""'" _ EHS•
Y+��'_ �
��P c
�Q��,�'(� Account No. �� ��
�� `�.'`d ` c.�
Revised DCHD(07/99) Invoice No. � � �
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