182 St Matthews Rd 1,�cc��� 9/a�
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. � , DA`VIE COUNI'Y HEALTFI DEPARTMENT �
r Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028 _
(336)751-8760
Account #: 990003081 � � • Tax PIN/EH#: 5707-78-2962 •
Billed To: Teresa &John Santis Subdivision Info:
Reference Name: � Location/Address: St.Matthews Road-27028
Pro osed Facilit : Residence + ' '
ATC Number: 3699 '
AUTHORIZATION FOR WASTEVVATER SYS'�'EM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST BE,ISSUED by the Davie County Environmental
Health Section prior to issuance of any building pertnit(s). This Form/Authorization Number should be presented to �
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA CO, U TION IS VALID FOR A PERIOD OF FIVE YEARS.
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Environmental Health Specialist's Signature• Date: �a (7�
, CERTIITCATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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. �
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Septic System Installed By:
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�nvironmental Health Specialist's Signature : { `, +~' ` Date: � - t
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CHD OS/99 (Revised)
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�^ � , DAVIE COUNTY HEALTH DEPARTMENT %�°�
Environmental Heaith Section
,��____� P.O.Boz 848/210 Hospital,Street
Mocksville,NC 27028 �/ r�
(336)751-87C0 _ �a y-�7�� �
IMPROVEMENT/OPERATION PERMIT
Account #: 990003081 Tax PIN/EH#: 5707-78-2962
Billed To: Teresa&John Santis ' .Subdivision lnfo:
Reference Name: Location/Address: St. MattMews Road-27028
Proposed Facility: Residence ' Property Size: 7 +acres
**NOTE�*Thislmprovemeilt/Operation Permit DOES NOT authorize the construction 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). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residentia] Specification: Building Type � � �u #People�_ #Bedrooms � #Baths �
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �•��12-C� 'Type Water Supply U��1-�-- Design Wastewater Flow(GPD)� Site: New�Repair❑
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System Specifications:.Tank Size ��C?�GAL. Pump Tank GAL. Trench Width ��Rock Depth �Z�� Linear Ft. "FU�
. Other: � � ���'�l pN �,(� .
Required Site Modifications/Conditions: ����— � l/�N��� �` � �` � �jv5�,, �i�����'""`
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IMPROVEMENT/OPERATION PERMIT LAYOUT- APP FFLUENT FILTER RISER(S) IF 6 °`BELOW
FiNISHED CRADE. '`***NOTICE: Contact a representative f the Da e County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m.or 1:00 p:m.to 1:30 p.m. n�t�e�y f installation. Telephone#is (336)751-8760.*.***
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nvironmenta]Health S,pecialist's Signature: Date: '�
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DCHD OS/99(Revised)
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� - DAVIE COUNTY HEALTH DEPARTMENT
� ,_Environmental Health Section , ,1
PO Box 848/210 Hospital Street. �� n��V�
Mocksville,NC 27028 `d"
Phone: (336)751-8760 �
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ON-STTE WASTEWATER CERTIFICATION FQR DWELLING
(Check One) REPLACEMEIITT o � , REMODELING�` RECONNECTION ❑
Name:��!��S,v �1 .�.n,,.��-s Phone Number: _s���-, �l -�i'.� ..l.'/G'i (Home)
Mailing Address: ���'� .S� .�i���e k� 1���- ,, �U��/ �j'/ Q 3`'7�' (Work)
//.l��s�.�f�N f �'!/!' .�.��.2r�'r�
Detailed Directions To Site: .�i�u,�� .:;� t..�,-.'�s� '%`�c� ( C��.-,�f,.��f.� .?7�/�f. ,J �J.�. �.�.-�c� G.�c�1 e �1cor:�'�-;rx.�.
!'�r'"� "..,Y". /f�nr �G�v'�i�' �c or�� �T"�`'r-- �'f`GjS"'r-/�Y-'�1 -,�'�� .:T 1'yJa Jl'IstccvS G/lr�,/f Cj_ �}� �, f-
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Property Address: ��`��`
Please Fill In The Following Information About The Existing Dwelling. .
Name System Installed Under: Type Of Dwelling:
Date System Installed(Month/Day/Year): Number Of Bedrooms:,_.,�Number Of People: ''���
� Is The Dwelling Currently Vacant? Yes❑ Nq�' If Yes,For How Long?
Any Known Problems?Yes❑ No❑ If Yes,Explain:
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling: /� / �/�b � Number Of Bedrooms: Number Of People:
,��'/� ,�,/ � 1
Requested By: .��"..-^G-f ✓f �%�^- �',.� � Date Requested: �"�����
�(Signature)
For Environmental Health Office Use Only
A roved ` Disa roved ❑
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Comments•
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Environmental Health Specialist r�/��`� / Date ��!'7 `"��
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'�The signing af this form by the Environmental Health Staff is in no way intended,nor should be taken as a
guarantee(extended or linuted)that the on-site wastewater:.system will function properly for any given period of time.
Payment: Cash❑ Check❑ Money Order❑ # r``r •�` Amount: $ �Q� • U� Dat�:
Paid By: � �Received By; �
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. Account #• �f`� �, � Invoice #• �(�1 �'"Y
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