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804 Wagner Rd , . . . : .�.;:�. ,,;;�: ,<:.3 �$a.r,; . .,. s x: . , r• ,; � , . .,r _�-- � -,: . . a : ` .. ..�..:.a t r '.` ,.� ,. . :�,. :�. ..�r.. ..:.',.-. "' v.: �;: . � � j ��:' ". Au�' RIZATION NO: � ;,�� ��'`DAVIE COUNTY HEALTH DEPARTMENT � Q ���" o Z ' � - '' � Environmental Health Section PROPERTY INFORMATION �,r ,} Permitt 's j' � P.O. Box 848 Name: �c.7� ���Lr.�'�,�'� r ��'��.�t.�i1�`!�?.: Mocksville,NC 27028 Subdivision Name: �, ', , / �,�:'t( Phone# 336-751-8760 Directions to property: C%l7/!�'%" !�` l��'��1 Section: Lot: AUTHORIZATION FOR '' .. �".��` WASTEWATER �' Jr�; i i=fr /���; .� ia. � G-�'�l .>i;'p',<� Tax Office PIN:# _ ,. ,� SYSTF,M CONSTRUCTION — i?'�-� � , J� Road Name: G-- h� � Zip: � �� �,•-� �+ **NOTE**T'his Aothorization for Wastewater System Construction MUST BE ISSUED by the Davie County Env'vonmental 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 Perrnits. : (ln cor�pliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � ' , �� " ' f�f: `"� ��� �� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � � •{-�,. ^ ''�,, / ,, �,J�'� "��Z. IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTA HEALTH SPEC[ALIST DATE ISSUED � �.�.+;v ,.,,�v.v-�.�.•„ :.�'�,.� .,,.,,,;�;r,' �-�r�.rr --r^�;,: b.�,:rw._. .-I'�""'°m-^;", `?`.�':^� �.`5r � i ' «., �� � - � , +� � ., "�7 , . r�' ��,•.ir -.-m:+7 't -+,v�.%::�,..�fr..� !�..+:r�.� �t`,'tA:.•or'u/�,....l��i �-�'.,:- ;�s,"; ``�� , Y ":... r1. . . . _� � �' . :� �.~ . . . �. . . �^. s� ��.. .� .... .�. . . ° .. � '. " .,_ ,. � " .� �' � � , � ,.. „+"v..' . ,,�y,{� � �';��. . Z . . . g�'��y7�,p7�7� q'� $T�Tr��)gp7�p 7�r{�+p� 7� pyyTA� 7�7r�+ _, ` :'�' :J /!• �lll�H1�ll1G.�l..�u.11a ll ]�I Il3�iE9u./111�Ai��l'�1lg,19�lE1�ll �� a .. f � �, u . , r�z�' ��:� �''� � �1W�ktOV�1Vfi]E1V'd'�11�D:OPE�tA'�'dON I'Edtl�tI�'S PROPERTY'INFORMATION ,Per7rnitf e s:� f , '- ' n, � . . :. � , � •. . , ..Name: ���� ,��r��',�.�. v"'' � . c�,�"�^'�:�'°'�°�'�r,�« ,, �w . Subdivis�ion.Name . . ., , � ' ., , , - . � w,.�?s�d`� '� ;� '��� � , Direstions to property;: � ��_" -'`�' , � , ��' � , Section; , Lot: � ak ;,�.` ��'�'``%` �`.a�t E���t t ��,;.-r :r'�1�aa� : � . '. . ,�PEIItMIT � ' Tax Office PIN:# 4. . : . . . g S S • ' ' .. ��; . .,� �, �. . . . � - - � ..... , . .- .� , , r�� .�� .�,,;.d ��tf' _ . Road Name: �- 1� �°L Zip: ' ° `**NOTE**This;Improvement Pernut DOES NOT.authorize the construction or�installation of a septic tank.system or any wastewater system.An ' � AU'THORIZATION FOR'WASTEWATER SYSTEM CONSTRUCTTON must be obtained from this;Department prior to the . . ; �constructionJinstallation of a system or the issuance of a building pernut. : . . . - , .�, - � (In compliance with Article l l of G.S.Chapter 130A;Wastewater Systems;:Section.1900 Sewage'Treatment�and Disposal Systems) . ; . -�� �` ..-+''� �� ." � ***NOTICE***1'HIS PERMII'IS SUBJECT'A'O Y2EVOCA'Y'IIO1V I�'SY'Y'� . <�3�"�'tt,,*� u �, ���,����.�,r,� '• `� �������-. pd.ANS OR'Y'EIE IlVTENDED USE GHANGE.YOUR WAS'd'EW[�1'�flt �t � ' ENVIRONMENTAL HEALTH SPECIALIST •' DATE ISSUED � � .`' SYS'd'E1�I.CONTRACTOR iVIUS�'SEE THIS PERI�%'g'BEFOII�, . . ,. , ,: . ., . .' •• ; : , : ,. . ; HNS�'ALLYNG'THE SYSTEM. .' � . , . , „ . , , . _ : . . , < , . . ., . . � , . _ . . ,., � � . , . _ � ; • � � , ... _ � .. �.. , ,.,,, , ; , . . . , . RESIDENTIAL SPECIFTCATION>BUILDINGTYPE.� #BEDROOMS • #BATHS #OCCUPANTS ° GARBAGE DISPOSAL:,Yes or No , • � - _ COMMERCIAL SPBCIFICATION: FACILITY TYPE. . #PEOPLE. #PEOPLFJSHIFI; #SEATS. INDUSTRIAL'WASTE:Yes or No ,, _ . , . . �.. , , , , . . „w, a � .� . :..; ,. y ,. .. . , ,. . ,, ,�; . , �. , .: , .. , , ,. ; . : ,. !f���/ ,� � -. , LOT SIZE ° - .TYPE WATER SUPPLY���� DESIGN WASTEWATER FLOW(GPD)��-,�[� NEW SITE . . REPAIR SITE��_ '.. SYSTEM�SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�.� ROCK DEPTH�f1_'LINEAR FI'.�� ,. . OTHER ' .� tl, , . , . , REQUIRED S1T'E MODIFICATTONS/CONDTI'IONS: , � , . � ., IMPROVEMENT'PERMIT LAYOU�$��(� ��..�R�I� �$E..Y��if ������S� $� �i�9� ���9 ���VII� ��I��: � � ' . , . . _ ,_ : , . , . . . . . � . , , , . . , , � ., . , . . ; • ' , � . � . . � . . ; .. � qi�. '� � ��� .. S . ' .' . .� ,. . � � � � . .. � ' � .� � �� .. � r � . . � ., _ ,� ' , �t'�� . _ ' , , . . ' **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM . • BETWEEN$.30-930 A.M.OR 1:00-1:30 P.M.ON,THE DAY OF INSTALLATION.TELEPHONE#.IS ����1� - , , , . '. �4��7`�$����f� . . OPERATION�PERMTT. . � � . � �,. � . ' . . ' � SYSTEM INSTALLED BY: ;' ' ,. , . . . . . „ . . . . . . . . , . � ,-5.. . . .. . . .. �. • . . . r - . . �, .��.� '... . . ',.. � . _ , , . , - ; . . � . . 4. �. . , n_.. . . ' . . �1 + '" ... i � _ . .. . ' � ,.. - � . . . . .. . �^ � ` .. . . .. - � . . . . .. . . . - �. : . _ . ' .- , . . . .. � . , . . . . . . � . . � -: .. . . . � , . . . � . . .�. .. ., .. � . .. ,-�. ' . �� : � . . . ' � . _ � . .. � . . , � . . .. .. . . �.. � .- � ... . e � �. . . . . . . . .i . . .�� . . .. . . , _ . . � .. ' . ' . .. ..:.' . . . .. ` , . .. . . ,. .. . � . - . : � . . . .i. . ' . . . - �t. ' . ... . . . . '. . ' . ' . � . , ' , - . ' . . ., . .. ., , ' .. . � . . . ` .. � . , . , . ' . .� � . , � . �. e . . r. . . . ' ' I � . ' . . � � .: : ' . _ � .. . . . _ . . . • • � . .. . .. � . , . , u �. , . � .. . �. . . , .. . / • . . _ . _ . , • . . . . � . . i � .�. .�� .. . � . . . . , � / .. . . . .: . _ . . . . . . . . . .. . .. . � . . � .. .. . . - '.. . �. ' : : . ' . , ' : J ' . AUTHORIZATION NO.:.• ' OPERATION PERIGIIT BY: � DATE: Y `���� � � **THE ISSUANCE OF'THIS OPERATION PERIGIIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE�HAS BEEN INSTALLED IN COMPLIANCE. ' WTTH ARTICLE 11 OF.G:S.CHAPTER 130A,'SECTION.1900``SEWAGE TREATMENT:AND DISPOSAL SYSTEIvIS",BUT SHALL IIV NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY.FOR ANY GIVEN PERIOD OF'TIME. . , _ . �, . � � . .. � :. . � � -�c . - . , -�; t��- DCHD OS/96(Revised) � _ , " , , , , � ' . . . � , , . . , ; . - . • .. . . �j , . , . . � � � ' � � � . . . . . � . �. . .. .. . . _ . . . . . . . . � , . .� . . , . � , ,. ' . . „ . � _ . ' . . .. . �, � , , , � .� , . .. , �. . �.. ' ,•. '. . . . . . , , _, , .yY . : ` . ..'; ', , , a � �`, . � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) � NAME___.� � � c�c�L-�-�' PHONE NUMBER � ADDRESS S�� `-� C� a-� r� 1� • SUBDIVISION NAME �� /7'1 0 G�S U � f I -� LOT # � DIRECTIONS TO SITE � � � DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED � TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING (� � �— // � DATE REQUESTED �' �� � INFORMATION TAKEN BY � !F � Thia is to certfy that the information provided is correct to the best of my knowledge,and that I understand I am responsible for ali charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93