143 Princeton Ct Lot 5 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 989900204 Tax PIN/EH M 5860-81-3295.05jdc
Billed To: J, D. Crews Homebuilder Subdivision Info: Princeton Lot#5
Reference Name: J.D. Crews Location/Address: Baltimore Road-27006
,Proposed Facility: Residence Property Size: see map
ATC Number: 2971
**NOTE**This Improvement/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 1 l 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 CON
�i TRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type '—i Q 'r #People #Bedrooms —3 #Baths
.T
Dishwasher: la Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: u Basement/No Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
//��
Lot Size �(73i}�1 2 Type Water Supply l-Eo iyeDesign Wastewater Flow(GPD)ZI.DO Site: New 121'*' Repair❑
System Specifications: Tank SizelDVOGAL. Pump Tank GAL. Trench Width 3tm�'Rock Depth 17 Linear Ft. —2>00'
Q� . _ 4�
Other: c3 1DVST ,1 gJ Tlo.� �- cs. j,\,ST ,Lt..- X-U+-
Required Site Modifications/Conditions: (�StALL b--� C-Njjjo- 2R� 04wr V6tx�
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a a.m.or_1 Q24 m.to 1:30 p.m_m the day of installation. Telephone 1-8760.****
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nvironmen"—faTReallIi Specialist's Signa e: 71 aD�—
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DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account M 989900204 Tax PIN/EH M 5860-81-3295.05jdc
Billed To: J. D. Crews Homebuilder Subdivision Info: Princeton Lot#5
Reference Name: J.D. Crews Location/Address: Baltimore Road-27006
Pro osed Facility: Residence Property Size: see ma
ATC Number. 2971
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(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 FORWASTEW NS U IS V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatu Dater
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this 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: ,�Invy\y So ft f V,zs
Environmental Health Specialist's Signature: ka�77LDate: J (D D
DCHD 05/99(Revised)
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Davie County Health Deparfamt
P.O. Box 9401210 116�tal stawt
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031117111-470
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s. ]tppl.icatio:a for: E1 Site iw'+slnaitivra I swroroemuat: Pe i.t/al'1'C 0 Both
s. VystdW to Sarvice* 6Y Nantas D Mobile Berea. D ftsimse 0 znftstn d other
a. It swaidemm: T people Ir oema _3�.,, N BAthzooau� ZS
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e. it bestaasa/:edmatty/other: Opwify tyre i POV10 „�� T staslw
GCwwodaa ! shottarle vanair ! hater coolers
1!r "miCV'lctt: d Swats istiMt" Watson US*" (gaslam pow day)
r. %yp* of watez supply: go'conety ,ei.ty 0 well 0 Cvmmardty
S. to you spate additions or a tpamlons of the fulihl tirle systems Is In asded to starve? 0 Yea 940
U Yes►wlamt type?
I•'"1b1AUR1'A1Vf***CZIENMJf)XTC0J1 TXMTHIE: RSQUIMD FROMM INPOKMATION REQUESTab
SELOW. Skber s PLAT or SITE PLAN AWSMSUBMMED bto ttieM r►Itb TM APgWCAT>EON.
Property Ditmlemdoss: 117„'26,j x ,j)2 x g j � WRM 13121MONS tfi*m vft)to tcROt'ARTY:
Tat 0f1k*PIN., . d -5,?,60 8r 32-gS, 5>d� US Wow c{�� ��e�1'o� CjoWrttz�•x
Property Addrealw Road Name 41-i et c e-m-i cc toz- L-eF�C' a B 1 L'r�1n4R� 1 (.EST. o t�
cityrzlp Aa-"j cc ,�LzZp.v `tac.e�oe1 co�,� , Lo'C 5 014 LETI-
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Kemps; �':NCE"iDt� COu R�
&"*a: ,� Sloth: tats � Date Property lamed: q- 19-0
1
This is to certify that the kfomodon provided Is correct to tine bet of uU knowledge. I wndentstad that tory permu(s)
iwed bere:afte:r Bre oebject to srspeaalan or revocation,w the*a phss or iateedW use ebaege,ar N fbe Wormatiod
ubatimma�i in tulle spplieatton it�fdsHkd it clwtgal. x+rule�ebal J ewr trfar alt dFerr�Tsrcecrrsd,jra�or
_1l}1s+a�gptteatlbar. I,knv b'y,tfwe toemst le#w-AtrtltoriiM gapresedafteefft Davie Cowdy Sera Deptrimeat
to ester upon above described property Iocated to Davie ComAy sssd swad by
to coaduct atli taming procedures as necessary to detenniae the due
DATE �^ IC(-9I SIGNATURE
T1115 AREA MAYBE USED IFOR DRAWING YOUR IiiTB PLAN i;Umeludt all ofNue failowbw RsisOmg sad proposed
property luta wad dimocnsioes, strwctnrw. ndmcks. wed sep*Wcatirrol•
V Account No.
Revia+td DCHD(67/98) .r Iatvotee Na
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�R.aG�m�J Cots-�a�.