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256 Spillman Rd „�._.:-� .: .r.c ...-�.:.. ' `,. P. ..'�.�'.. �” .: � ,. i'M1w t1.�:4 .�:- 5 �y ��. � : � v.�_'a-i' =: ..t�.a. T t ' . ., �.i L��' � '' 1. 'y.v . - � ,..�.a ,- u - .R � `�., . .._:. ...:: a.�.. . . r:�� .� ..�:. , f " , ' Permit�ee's , DAVIE COUNTY HEALTH DEPARTMENTf ��%G`G�`� C ``��l`S•�`��wr' ,� � Name: �'! � �'> >i' "'v �Environmental Health Section PROPERTY INFORMATION �, _ �� .,, .� �y P.O. Box 848 Directions to property: �` � r f'�� � Mocksville,NC 27028 Subdivision Name: �-'' / ,r , � Phone#:336-751-8760 � r.,7 f�.�!'1'./f��'�!r'J�,/,�! "" G5r°t/�'d!./'✓!'.f( Section. Lot: / '� , �� / AUTHORIZATION FOR ll..�+' `�; J�/V � .r!,�.�/��Y/ ✓ WASTEWATER Tax Of�ce PIN:# _ #� SYSTF.M CONSTRUCTION . AUTHORIZATION NO: A Road N " , _ �.�6J ame: . Zip: **NOTE**This Authorization for Wastewater System Construction MUST BEiSSUED by the Davie Counry 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 applying for Building Permits. _ (ln c�pliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,q 4�,,,r,�' ` ,,.,,/,,,/` �) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION G'� �''"" /'� ��f f� ��/ D� IS VALID FOR A PERIOD OF FIVE YEARS. . ENVIRONMENTAL'HEALTH SPECIALIST DATE ISSUED ,.,� ' RESIDENfIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS�#BATHS,�#'OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILTI'Y TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No LAT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)� NEW SITE REPAIR STI'E / ,/ SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUIvIP TANK GAL. TRENCH WIDTH v�a�ROCK DEPTH �`�*""� LINEAR FT.��„� � �y/i OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT , ,.r, "'`z � . . . .. . .. . . . . . . � � �y� . Y'. . . � . . . � � . ' . . . . . .�, . � . � . . ' ' � � . .. . � . . . . . . . E�� �+�' . ' . . . . . . / . . .. . / r �� � F t'.,.. "'; � �, �<: ^��� • `� , ,�,�� I . . . � � . . . . . ' ' . � � .. . . . � -}:�.,4 . . .. .. �I . . . �.�-. . . . � . .. . . . . . . .... ., .- � . .. .. . ' - . � . � � . . �',�wj. . � . . . .-. . � .. . ' . ; . . . . . . . .. . .... , . .. .. . . . .. . � . .. . . i . . . . � .. . . .� � � � . � � ' . . . � .. � . . . - .. � t �, . . . � . . . � . � , � . . . �. �. . . .. � � � . � .. . � .� t, . �.�� ,.. � � . . � . � .i . . . . ' .. � , � . . � . . � ' . . . .z .. - . . . . . **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9;30 A.M.OR 1 i00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT _ SYSTEM INS Y: _ B � . AUTHORIZATION NO.E��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 07102(Revised) � � �, ti_ ' %9 •,�.,• ,a..' .:.,�., �r..; . r �.W, rw �...:�..��, , ..,wr �.�w.ir .,. .. ....r.�,.-«.. ,. ., ...c '-r � •�4:. • £r�e m��.'s s -' � � ,r ` DAVIE COUNTY HEALTH DEPARTMENT r/� .C� ��r �'s`�`� � r..,� ) ,�,•!� � N��' '�ews" �'- ,�� •r � �: Environmental Health Section �PROPERTY INFORMATION �.� ,» . �'� . • ; � P.O. Box 848 DirecuQns to pwperty: ��r'{��''�«�•�'' ' +'�'"'T`�ad�r���� Mocksville,NC 27028 Subdivision Name: �'"': �-�'_ � Phone.#:336-751-8760 , . _�._j.���''�11:�J, �; r'.� r��� �r!`r.�:i'��'"�� Section: Lot: �^";`,; t . ' AUTHORIZATION FOR '� r , . �. � �� 1 % w. WASTEWATER �''f•+�1't.;�t,� � � ,�•�,� ,�,� �,�.�'�f F .: Tax Office PIN:# - - SYSTF.M CONSTRUCTION AUTHORIZATION NO: ����� A , : R�a�d Name: Zip: � **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the.Davie County Environmental Health Section prior to issuance of any Building Perrnits.This Forrr�/Authorization Number should be presente�to the Davie County Building Inspections Office when applying for Building Permits.` (ln compliance with Artide 1] of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �/' ,/ ���,./',�` ,- * � . F�,/,/'�y., ` • ***NOTICE***THIS AUTHORIZATION.FQR WASTEWATER CONSTRUCTION �c �f y"Y'',; ��..�.'-�,,,r� .� ,� F.. r� �}�" � l • �'S�,f°.,�' t � IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTA�HEALTH SPECIALIST : DATE ISSUED � - 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 A TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)� NEW SITE REPAIR SITE / 'T, . ir SYSTEM 3PECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� �ROCK DEPTH�;LINEAR FT.«� . ���� OTHER ' , ,; '', REQUIRED SITE MODIFICATIONS/CONDITIONS: ' IMPROVEMENT PERMIT LAYOUT r�`' . —. . ',i , , , .._._.._. , . . _ .. - . . � . . . .. . . . . . - � Fc': e'�.� . , - �� �. , � . . . � , . . . � � .�. ... ,� � � � � � � - � � � ., . . � � � �. � .. . . . . . - . . ... � . . . . . .2. . . . . .. . � . , . . ' . � . . . . . . . . . ' M .!}.. . . .�. � � � . . . . . . , . . +,�� � .. �. . . . . . . .. . . .. . i. ' . . , . . � . . . . . . . . . n i .. � . . . . . . . . . . � � . . � �. . . . . . . . ... . .. . � . . . .. . "..'_� . . �. . . � � . . � . . � . , ..� . . ' -_ � , � � . . ' . , . � _ . �.. . . - . . `�1. � .. . . . � � �,�.. � . � . . .. :. . . . : . , ' �. . � . . � . � . .. � � � .. � . .. . �,� . . � � . � .. . � . . . . . � . " . . � . . . , . . _. � . . , .. . . . . ! . ' . . ..' . � , . . .. . � . . � . **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 TH$DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. ..._.,�,: . OPERATION PERMIT ` 'SYSTEM INS Y: I'� l� ' �� • " , . `8 ;� p� , / }' �, ,+ ' .. . . � _ . . . . . . . . . . . . . . . . . a � . � . . ... . . .. .. . . . . .. . � . , : . � .� . . � . . 1r � � . .. .. . � . . � . . � . . , . ' . . . . . _ . :¢ . ' . . . � .� . � �, � �' �_ . . . , . � . . � S AUTHORIZATION NO.�OPERATION PERMIT BY: DATE: �� *+THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOV$HAS BEEN INSTALLED IN COMPLIANCE ;'` WIT'H ARTICLE 11 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. nCEtn ovoz Rtev�s�a� " _t ,,, , , _ �, �+ . � . „ � _ ; , . , � , ... . _ . , .,. , � , ,_..., � ;�.;,, , _ , _ , . , , , ',_. .�. . ...: s . + �n •- � o DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION y`' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) M / �/ � Q # NAME �� cZ q'� /` � � � PHONE NUMBER ! I �"' �� S� � ' ADDRESS � 5-� �-A� ( 1 M-�-.�►� � • SUBDIVISION NAME . � ( YY�, o �l�S J 1. � I C. . 1 v �- �oT # � . DIRECTIONS TO SITE g d 1 ` L—�-�� °� '''' � � � ��r`'w—� �� . � � �'�' � r,eQ� 1/�.�o�..�s C�.�.�_. �31�-�- In�� Q R - . DATE SYSTEM INSTALLED_��NAME SYSTEM INSTALLED UNDER � �-� K � �� � � TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED �' o TYPE WATER SUPPLY �,��I�� SPECIFY PROBLEM OCCURRING �� ��� "�S � -- � � w _ t`. t—�. C e..r.��lr� \ ��O DATE REQUESTED � / �' J 3 INFORMATION TAKEN BY �"' �' � Thia is to certify that the information provided is correct to tha best of my knowledpe,and that I understand I am r�sponaible fo�all charpes ineurred irom thia application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rsv.,/93 — _� � .� . � . _ • �, DAVIE COUNTY HEALTH DEPARTA1E;uT SEPTIC TAl`1K PERAIIT ..' � �� [":�:: af Bedroorns � Date � -_/L� �' �� , :.zw. p:.y��i; is granted to _ for the ir_sta.11ation of a septic tar�. . .��, �nc ��:sidPnce of �./c._c� '�t. . ,.� Address �,.;�. .ir°F.,• '�`.�r,�<t��a _. __.__.._. �ui�.d�r.� �ontractor `^ l� , � Address ���yvwv���-� n/. � � ..�__� 3�:Tai:1: T,�.^;r Specizica ions: Length Z�lidtn� Depth Capacity Gal. � :rz� __� - > �1 � ',. , ,� ;; a + ' ! %', �,, .� ��<;�-d-z� :Ir�� _ac u;� .r s Nasne �-,c Address � � � - _ � f?c?; oi lines_._� width in. Total Length s�"z ft. .:io. of Sq. Ft. _ �' �ra � ��_ `i��-_e o�' f'i ir.ei• material �fi�'s� ���1� � '.�� Total tons� used 3 � ^__.._.___.._� - - .�:n.:.�a�<<r: zequirements• House Trailer �` Tank Cap. €i00 � : Sq. i't. line �:OQ � Two-bedroom house . 800. . .. ._. bG0 Three-bedroom house 900 � 90C� , .. . . . . :?o o�1e srall install a septic tanY in Davie County without'a permit frota the Health Officer . _ . . . _ o� t::.s a�ent� __ . .. . . _ .. , , , . - �.<�:� of �'�i.r.a.1 a:?proval - _ . Signed:. __�� . _. . . .. __ . .. . ......_ - S�,r�ita��i�z T 1�ereb;% :ertit�r that the above septic tank has been installed�-accordin� to;,s�ecifica�:,ions, . . . _ S'igned: _� � �'i'"` � �-'� « - �,�--�-� Septic Tar.1: Contracto�- I�do`.e: `y!al�.e ::ket�s`�•. of dis�osal system on bac�. of sheet and mail to Health Center, Nacksville.. '•a��z�sx�oY1 °.za�.ua� qiZ�caH o� Ti�euz pue �.aaLis �o ��Eq rzo uia�s�s Tssodszp ,�o �;a�.a�� a�j�jn! :�:+OP� ;