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144 Willie Cook Dr
Pen�ctee's �%,. , ;--''� ; DAVIE COUNTY HEALTH DEPARTMENT / °�' I �'Z� � a s � Name: ��t��l� �" �-�''`��;`� Environmental Health Section PROPERTY INFORMATION ,� � P.O. Box 848 Directions to property: �f f�tf` C,'%�:�'�'�����'�'�r t�-''j�qocksville, NC 27028 Subdivision Name: � � ° �'"Phone#: 336-751-8760 � ,,... :. ''f / ,i�. ��>,,/ j�=Z i',�d.f,f,;.r�� f 1'�,�`i �'��.2'��✓�`'���"� Section: Lot: AUTHORIZATION FOR ,r•r..;"pf�r*�-" f,'�;� r�;;;�.�',,fi;,f� .''*„,t�jt,:ji/� WASTEWATER - - SYSTF,M CONSTRUCTION Tax Office PIN:# ����� t A Road Name: Zi AUTHORIZATION NO: ti p: **NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie Councy 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 compiiance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems) _� i ` %' + ' y""•^� � i s ��i,� / � - ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION �. �; �f t �i.� ,✓�,�- p'�.,.�`'� .� �;'', -"�+,/• � i � : , i��.�. ! �,,�°,.,,/���. IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE 1SSUED RESIDEIV'TIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS� #BATHS�#OCCUPANTS �_GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFI' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY ` `� DESIGN WASTEWATER FLOW(GPD) 1��� NEW SITE REPAIR SITE �-� SYSTEM SPECIFICATIONS: TANK SIZr;/��`�� GAL. PUMP TANK GAL. TRENCH WIDTH�._t�� ROCK DEPTH� LINEAR Ffi i=�ll OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT�YOUT , � . . —'f,r��;�r�C ..�� l i�� � l _ ./'' � „ �;��, � � �� �'- ---••.,�,,,,��� �" fl.. ,,1 �� �"`..,w � ���t� - r��� �'� l� �rl �-f� v , r.� �,` ,,s� S �� � S`l . � � 6 ' r�l � . �/� ��� � r���� ; '� r( C' �' ,�� � , � ,� � �� ,/���E � t' � � �, -� . �'� � ,i � �''� . v� �' I. � �, � � �' . � ��. � .�,� � �� FOR FINAL INSPECfION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMI � � Z��., �1r SYSTEM INST LLED BY: ����� ;� � ' �µ � . �e�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 1 I 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. DC[iD O1J02(Revised) �jC.`C.�,� ;����� `��'��'� �a�f. ' r ��.:,,�, nT=, y� t /� . ^�.� ��'�n . s„,,,� ...r.,,rw.y. . -�,.,-_• Ydti:�.^r� A�:._- r����-��`��svF. �V� � 1�1+'n��.4'i�-.w�•"k��'�{`+��. . '„wlllva'1'�'�L.-'."��C�Y�'f'rf�f`.`.'�Y'3•-.,/"V_'�I.,('�^�S"" N�v�.y�ey,r..�t`"-^ �v'+.y.,` yf .. � . � � -� ' � ' . . ' �� . ��� ! . �,� � 1. . P ri:�tee'S �'"�` ° '�t , �l�V�IE C��JI�1B'Z' �1[lEA1L.�'�1[ �IE�A]l��'I�EN�' ' "�`�Nam"e ���"��� �'�_�'�:� Environmental Health Section PROPERTY INFORMATION '� P.O.�Box 848 � �R,_, .�,�. �,��� �����``:�y ,.. ,��'�"' ; . , ` Directions`to property: � ''�� Mocksville, NC 27028 Subdivision Name . ' ' � �`��':.Ey��'`�;:�`�`�"`�` ,�I.., �W ,�`t'��` ��i���";��r.��.���Phone#: 336-751.-8760 _ � f ' � y, , Section:� "'Lot: ,� '�, r- , ' �i AUTHORI7,ATION FOK , . ;. h„�:,. ' ���� ..� � ,.� � ', �'ASTEWATER ..'r .. � .� ;�,�''� F�:�f „�- �f` .�'� Tax Ot:fice PIN:# _ _ - `,SYSTF,M CONSTRU(;TION - '; � AUTHORIZATION.NO:° ������ � R�ad Name:. Zi'p: . NOTE This Authonzation for YJastewater System Construction MUST BE ISSUED� : �� ** ** by the Davie Gounty Envir�onmental Health Section prior , to issuance of any Building Permiis.'Th'is Fonn/Authorization Numner.should be presented to the Davie C�unty Building Inspections :' �� Office wtien appl�y,ing fo�Building�Pennit�. � � � � �� p " , r � � Y A,Wastewater Systems,Seetion .1900 Sewage Treatment and Disposal Systems) � (ln com liance with Artide l l of G.S.Ghapter 130' „� ', � ����°`��``; ��, � � >_,�.�, �;d ,�'��4 �***NOTICE***THIS AUTHORI7ATION FOR WASTEWATER CONSTRUCTION � bt' ���'y►�-^�- W�y `�'���'�*^� �.�+`�,,,� �� IS VAiLID FOR A PERIOD OF FIVE YEARS. ° ENVIRONMENTAL HEALTH SPECIACIST Dr�TE ISSUED ' ; ° . ` .. �� �, ' , : ,: RESIDENTIAL SPECIFICATION:,BUILDING TYPE o/" _ '#BEllROOMS�_#BATHS_,�#OCCUPANTS�% 'GARBAGE DISEOSAL Yes or No h —, ' ° . -" , - , : ,. _ i .,,, � COMMERCIAL SPECIFICATION'. FACILITY TYP.E ' - #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No�'" . V , ��`.�' � ' � �. LOT SIZE T,YPB WATER SUPPLY '�:� �� DESIGN WASTEWATER�FLOW(GPD) �� NEW SITE . � REPAIR SITE � , ..;�, � tw., �, ... ,r , ' . ��/ '� '*4,,� 'i .,.t J �5�;,,,1� ` �y, - g`�" , �� SYSTEM SPECIFICATIONS: TANKSIZE/�� GAL jC PUMP TANK�� GAL. TRENC_H WIDTH ��� ROCK DEPTH iI� LINEAR�FT����' � . r. ' , . OTHER , . ii . � : " , � � � �� � `k � � - � � �. �r' � REQUIRED SITE MODIFICATIONSICONDITIONS:� � "�� � � � � � � , , , . .„, IMPROVEMENT PERMIT L�,AYOUT . „ r ' � �. , , . , — ' ;, i. , `�`:.. , � w. _ �li1l''� � �'� ` -� -.� , . , � , , ���� ;�, ' � �� �� � -� ��`. � � � � , � � ��w� h i v � , . — � . � �—� ��� � . � ii �� � � ,,al��� : , . � .�� ,�ff� . � � � - �.. � �r � � � � ,y . � . ,. i. . �, � � 4 . . . � :.�r � 4 y � � 4 � � • � �,. ¢. �{,�g• . � . �Y q � ./ � , Ir .. ��' f {4.l,` . . t��'� S�� � � ,;� 4 � �� ,; , � ��� � .. : r-�/1- �' � ��, � �� � . � � - � � �� � � � . � -� _ . .�� �` ; ¢, ,, ���, � � � � r� "i � � �� �°�j - � � „ � • , - - , : i 1 ,,., � ��� � � ��� ��� s�::� , . � , n � . �� ' . , � , � � � - . �� �; . �� � � � � . ... , . ,. _ . i , , � _ . _ , ., . , FOR FINAL.INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760: ' , � , , � > : .' ... ._ � .[ . . � . , ... i r/� � '�t � - OPERATION PERM[ r °, g �-7�- � e � � SXSTEM INST LLED BY: � ��'"-��� . , �,,,� ` . , � � , ' F _ �i'' ,;�: , ,' , � � �- , � �yt/ `y ` � , '. ,a � r �i, . — �(C1� ' . ` ,. . °F. . � ' � . . . . - - � ' �. � � � .. : ... , , . _ , ... . ... ' . , - � . .. . �. , .� i, , , . ' , . . - � .� ' . ' .. .. . _ . . - . - -. .. _ _ ' : . . � . - y F.'g` P , . �,� � . �� �� „ ,,. '. �.. .,.,:-, . . . � . - .. , � .��: �_ _.�� . � .�. �. . . . ' . . . �. �- , . . . --,. , � ` � . . � ,. . . . ... ' r , . ' - ., , . . . . I� . . 4. � . ' ' ., . � ' . . � � - . . n �. . , � _ . .. . .. � _ . . ` . . �. . �,. . - , . . . � . . . ,. , . .. .x. � � . , ' � .� �. I` � � � = . � . ' . � _ . . . . ��. ,. � . . i . ., , . . G �; � ' -. . , I � . .� � � ,_.. , . - �. ,. �. � . � `�` .�i � AUTHORIZATION NO. ' �:;OPERATION'PERMIT BY: � ;DATE: � •, , � F ; _ ��"`�� �, � *"THE ISSUANGE OF THTS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRTBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE : WITH ARTICLE 11 OF G.S:CHAPTER`i'30A,SECTION'.1900"SEWAGE TREATMENT AND DISP03AL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILYFORANY GIVEN PERIOD OF TIME. � — ,° r � DCHD02/02(Revised)' � ` , 'L ,�''��'r`�C"`^e"�.. �� / � I . ' .,,.. �I'�-V: # � ��� ^ ' �. �, . - ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848%210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FO DWELLING (Check One) REPLACEMENT❑ REMODELIN� RECONNECTION o � Name: �r �LL! i- •L'�, �` /7 ��� ��� hone Number: ���d '7'/�� (Home) Mailing Address: � � � � '�' G � ' %r (Work) � v.� �� L�..�' � � / 1 Detailed Directions To Site: �� Property Address: Please Fill In The Following Information Abo �The Existing Dwelling. Name System Installed Under: G�///� � `�/ Type Of Dwelling: Date System Installed(Month/Day/Year): ? Number OE Bedrooms:�Number Of People:�_ �`/ � _ Is The Dwelling Cunently Vacant? Yes❑ No.�" If Yes,For How Long? Any Known Proble ?Yes❑ No❑ If Yes,Explain: �}���fnr� !"h y�� .�1�:.s�� — � r�' . 'L� - J ��,��� `E ����t�'Z / Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: Number Of Bedrooms: Number Of People:� � Requested By:� c: ^� Date Requested:��//�S (Signature) For Environmental Health Office Use Only /�0.l� Approved � Disapproved ❑ � � � ���� � Cominents: �('C �/l / �.'��/t/ � Environmental Health Specialist (,����� Date ����--�/�'�J`� '"'The signing of this form by the Environmental Health Staff is in no way intended,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 #: �� 5 7 Invoice #: