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269 Walt Wilson Rd ; , _ , ., . M,.._ � . ., . . , . .. ' . ,..�d^' � 4�''.,-i:... , ._ , ` - . ` . .S�. � • ' � . � . � . . � i�„� �-� - ... j. i� �i � C l� 1.�+ � � ;�.� r�l: fi ' AVT:-IORIZATION NO. j � � �g�}DAVIE COUNTY HEALTH DEPARTMENT `� _.._..._ _---2=F�c�---� , '� � Environmental Health Section PROPERTY INFORMATION • ' Pefrmittee's � � P.O. Box 848 � Name: ���"� ����'f�~"''�' Mocksville,NC 27028 Subdivision Name: � --- Phone# 336-751-8760 Directions to property: ��V�� �`l ����"�u� Section: Lot: t. � ,!` AUTHORIZATION FOR �;;_� f��,J�.,,.,1 �,j �„J �,,,,j,n�-i- WASTEWATER Tax Office PIN:# - - SYSTF,M CONSTRUCTION �s^Ji�'=��J �.f,% Road N mJe: �l'.���.7 �,...1�+...':.J..1Z�p: .'._'%.r=`'�. **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County 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 compliance with Article 1 I of,G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) _ , , � ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �„,�„�..ry,,`. �' .a,_. �"` ,: S U,Z.. IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRON ��' ALTH S'PECIALIST DATE ISSUED � rt-1 _",r.s+�� ""t i^h�v�.,n��w(� w� `G^N""-'^- �,,.•-/y^�� i^r.;rV'n.^`t��-.�`-•�l,rihrt�.,�-v Iar.,'.r'. :�^'..'.`..r-^.,.r'¢T:+ I. �;.y� � '�'R.,('4 t< .�+ �:L,u.:-v,Cll. �y �:•s�-k -"� l : .��- � 1 "} � � # '+, r . "„+. ` � `. �<� . ��.� ��#� �a� �„� � � . .. , - : �, �..: �. . �.� � ����� ��v�������,���������� �� : � �.. ,� �-.-�`�� � ,, � � � ���. 'y . � �. ,' :. �. . . . :. : , ORMATIC)N � _ ;�. f'``; , � . ` . . ,. .+����:Permittee's.., , ,�� �, � ��; ':� ; ' � � �Mf1P�tOV�NfilE1V'd'.�ND OIPEfltA'p'�ON 1PER1yYITS - PROPER'I'Y INF . . ��;,,,�,�-,�.� �'�� ,�.�� ,t�� ' ,�. � . � Name::� : _ �� , . -. � . ,�� . � � Subdivision�,Name: � � �� � �^. ' , ,�„�,,; , � . . ��, ,` � . Directions to'�property: ������' . �"� ����+��'� � - � 'Section: Lot: � .; � a.:_� �: �_ � ` � � . � � , :., . . � . , ' YMPIItOVEN1ENd' . • . �""=�•� _. ��'�- � �.x^,t, s,_'��� ��.�1�$'. ' PERIVIIIT ,` Tax Office PIN'# '. - - �'.�s�;;'�,�,�:;� �� , . < :. �.. . � � RoadN m�:'�.��.s �i,. 1��,±,,,.. tZIP. �t�F4-',. .. , • . ... . o ., . , .. . : , , , . . . . . . . . . , �' : **NOTE**'This Improvement Pei�mit DOFS NOT authorize the constniction or,mstallation of a septic,:tank,system or any wastewater system.An � � � .ALTTHORIZATION FOR WASTEWA'TER SYSTEM:CONSTRUCTION must.be obtained frqm thiscDepartment prior to the. . . ' :�� :' construetion/installation of a'system or the issuance of a�building perrrut .. :. � � ' . . � �(In compliance with Article.11 of G.S.Chapter 130A,Wastewater Systems,•Sec�tion+.19��Sewage Treatment'and Disp'osal Systems) , ' ..;. ,i. ; _ . , . ., .�.. . , � . , r� r .,.�x. , . , : ; ,��`�,x. , �`- ,' ; � , �***NO'FTC�***'d`HIS;PERMII'Y'BS SLJB,T�C'1'TO�VO�A'd'IOiV IIF'SII'I'E � ., ' � " .PLANS OIt'Y_HE IlVTENDED'USE`•C�dANGE.xOYJIIZ WAS'I'EWA1'ER ' :'*�,..._�:,�r` . , ,� �.�'",� � "'+„. : �.^� �:M. �- � �� . *^��'�", ' -r ' . , .. , ,__.. . , . :. . . . ,SYSTEIVI;CONTRACTOR MUS'g'SE�'I'HIS P.ER1�ITd'B�FOR� ENVIROI�M N�'kAI,FCEALTH SRECIALIST' �.DATE ISSUED' • , - � -�,�' t'.�*. . . dNSTALLING T'��BYS'1'EM. � , . = . ,; t•. ' - ; � :. . °� `� . '. s . : ' s '. �,. •.. < `. , ,, ,,, . . V RESIDENTIAL'SPECIFICATION�BUILDING TYPE' D S� #BEDROOMS�_#BATHS� � #OCCUPANTS � .�i GARBAGE DISPOSAL.Yes or-No : ; .... :. • ,4';'^,'....- . . . . , , • .�. . , �, , . COMMERCIAL SPECIFICATION: FACILITY TYPE t#PEOPLE . #PEOPLE/SHIFI' #SEATS INDUSTRIAL WA$TE•Yesor No • . _. :�° ' .� .s x� �. z '4 " �=. _- • r =x ` , ° ` y . �;o� � t , ;r LOT SIZE TYPE WATER SUPPLY �"����" DESIGN WASTEWATER-FLOW(GPD)��'� `NEW SITE ` ' REPAIR STTE ' � , , y - "` . . � . . . : ; ,�. . , �� • . .:. � � �� _ .. - 8'v �.. SYSTEM SPEGIFTCATIONS: TANK SIZE ' . � � . '� � GAL. PUMP TANK GAL. TRENCH.WIDTH �� RFTEK`DEP`fH',�_ LINEAR FI'„�� , , � , , . . . . - ry . � . � ��, r�L'����� i'��� 1�1Si'A� t..� u5 ��� D. C. ;� L ,� , w�.� , . , , � '. OTHER . • � ' �. : .` ..' . ' ,. �` c7GG �Jlt..�� . � �ro.� ' REQUIRED SIT'E MODIFICATIONS/CONDITIONS:. � �'i �V� �� ��—L^ . ; , � , .:, ; , . �'�..'�1n� .� ��.�o��.�cJC�'t�. ��T�� F� ��..i�S���,"To i�L -L�►C�T4� '�2-� � . ,�. IMPROVEMEiVTPERMITLAYOUT����� ,��:��g �g�.Y��{f ��B��tS ,%F'�,9;. �..�' �Ib�ga4{� �x�D'�� , ; , . . : z .0�� � .�.-�.�„ , � . . _ . . � � � . � � , . ��.� , . , , . . , , - . . � . . . . � :, . . . . .. � �„ . . �75' �,, s��'' . . . . . . , , . . : � . . . � , , , , � � . . ��� . , , . � . . , . _ , . . , . � � , . . . . . a . � ��� �v _ , : � , � � . � ����.� - � : . �� � � � � . �` � ���� �,� :�� � . .� . �� ; .. � : :�� ... � � ��...��� . :�� . , � i: ' .. . � . . .. .. , o� .. .. . . � . � . -� .. .,.. .. . . „ . , .�.. . .. ,�. 1. ... . .. _ ,. . . . . . . _ . . .... . � � . , . ' y . . . . . .� . , . , . . . . . � . . . . ' � � " � . . ' . . . � � . . . . . ., � . .� �. . . . . .. . , � ����• �l r�:l� t r� �c�C`.�� � ` **CONTACT A REPRESENTATIVfi OF THEDAVIE,COUNTY HEALTH DEPARTMENT F.OR FINAL INSPECT�IO r�F tTt I SYSTEM BETWEEN 8 30-9:30 A.M.OR 1 00-1:30 P.M.ON THE DAY OE INSTQLLATION.TELEPHONE#IS j4=�7�� � • Q�,�9���fl-1dy'�s@� � � �� OPERATION PERMIT '. , . � : r� . , , . ,: ' 'L��'�� ' , . . . SYSTEM INSTALLED BY: -�C�L� �.. i . �`i"' _, [,.- . , , 'h � ' . � . : . • - ' � ° . � . �� . , � . � � ; : ��L ��, . . , . . . , : . ., . _ . . . . . , � ' . . ��. ' '�.. - y : . : . �,a �.. . � / . ' ..'. � � � � .m. .�. ". , � ... I , .: ..' : ' � _;.. ,. .. . �::�. ' • �. ' � ..� . . . . , . .� . � ' . _. , �� . � ... . � . .. . �� . , . � .� � . . ., .. . .. . � . . ' . . . . . � , �a � , �,� , _ y � � � . . . . . . . : � . . , . .. . . . . , _ . . . . � . . . . . . � . . . . . , �.� . . . . : .� e � _ . . . - . . , . � � . . . . .: : . .;: . „ , . . � : . . . _ , . , . .i , r, ; . � ; , , . . . . „ . �f � .. �I �5 � . . : . . ;l-, _��. AUTHORIZATION NO. � 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"SEWA�GE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A '" , ; GUARANTEE THAT THE SYSTEM'WII.L FUIVCTION SAT15FACTORILY;FOR.ANY GNEN'PERIOD:OF TIME: � .' ' � ` � f.' .DCHD OS/96(Revised) . '. •.' ., ,, • , ,' . . • ,. � , ' .. . � , : � . . � � • � . � . . . " , ' � , . « e ,+ , , � , . . , . . . .. .. � , 5 . �?�,. = ' c, , � _ • '.� ,:,., , , } . . . . .:, . . _ '. � . . .... . ''. '.•_' �: r�£x . .. ' . . � , . J--e--�� �`� S �- �- ;3 a �.�' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ''` APPUCATION FOR IMPROVEMENT PERMIT(REPAIR) � NAME � � �-�-`� � U� r.� eRS �� ��� � � � � � � PHONE NUMBER � ADDRESS � � c? �/� P� L-� �h.I l�-S a"� � SUBDIVISION NAME N I/�Yl o � /�� J r !l� �, � LOT # DIRECTIONS TO SITE � /'�Gt l-�� � c� �`' �--e-� 1— � � � DATE SYSTEM INSTALLED �a �� s. NAME SYSTEM INSTALLED UNDER ? � TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 3 TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING ��-�-✓`^-,��� — `��^ �� � C�- �- � � ..e_ �--6 �1 � --�--R-e-e f�o a -�-S �' � � DATE REQUESTED � � Z INFORMATION TAKEN BY � � This ia to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application. � SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93