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1829 Underpass Road Lot 3 P/O 2 Section 2X6 AUTHORI ,ATWN NO: Q 8 % 3 DAVIE COUNTY HEALTH DEPARTMENT *'. " Environmental Health Section PROPERTY INFORMATION Permittee' s P.O. Box 848 Name: Mocksville, NC 27028 Sub•Tin/Gtlep Phone #: 704-634-8760 Directions to property: Q !.1/l�R Seco Lot: AUTHORIZATION FOR WASTEWATER Tax Of e IN:# - SYSTEM CONSTRUCTION l Road Name:? **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. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION , s' % .1 �'� t/) j /�i'' J IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH"SPECIALIST DATE ISSUED r,a 0 m \I 0 6 5� c _ Z y p � z 9-•-, O s rot" CERTIFY 3 III ,y,yt-7N • Fore• CERTIFY THAT THIS MAP WAS DRAWN UNDER MY SUPERVISION FROM AN ACTUAL FIELD SURVEY MADE UNDER MY SUPERVISION ON /)bu la rf.1 195f; I FURTHER CERTIFY THAT ACCORDINC TO SAID FIELD SURVEY, THE PROPERTY LINES AND LOCATION OF ALL STRUCTURES ARE ACCURATELY SHOWN HEREON." REVISIONS .• uP Ota.TC. 3-11-8 r i. f, I•F L-2 't (- SCAI.E: III ... 0 Iro N 01 PROPERTY OF �c� 6 4 I ►�1 V`(, G '. 'FL �: N �/ U c, - GUPTON-SKIDMORE-FOSTER ASSOCIATES ENGINEERS — PLANNERS— SURVEYORS WINSTON-SALEM, NORTH CAROLINA A DIVISION OF OUPTON•FOSTER ASSOCIATES, P,A, MAP OF: �'" fC �E; - I�1 WOO I_ K L. LOT NO: 2 ��'� �, j _SECTION: a PL TAY. MAP DE TAX BLOCK: COUNTY, NORTH CAROLINA NOB 1a.( L,, ���� DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS Subcjiui �'lr'C�lna - Directionso property. .`f -i e'.2SS Section` Lot: PROPERTY INFORMATION IlVIPROVEMENT PERMIT Tax Off el�i'PIN:# - - RoaJNa e• **NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH`SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS sT # BATHS --Q_ # OCCUPANTS � GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE It PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes orNo LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) G D NEW SITE REPAIR SITE Y SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 1`'�✓ !eD /con x 16 "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 6348760. OPERATION PERMIT ��d7/L SYSTEM INSTALLED BY: is n K q� Obu AUTHORIZATION NO. 69 `° OPERATION PERMIT EY: \ ) t._/ ,� DATE: gtls A� "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 "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. DCHD 05/96 (Revised) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION ,PElmitteeK� s;;, � Sub �'sien.AT��/ Directions to:p;operty: Ta�',��.-,i�'f;�J.� - Section: 3 f Lot: IMPROVEMENT , PERMIT Tax Office PIN:# - - RoalN me:Cf t"t R5LIp`".d 0 **NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS Q # OCCUPANTS __-J— GARBAGE DISPOSAL: Yes or No- COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or o LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) Q NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 18' LINEAR F Q�7 n`ruFn REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �1 1 l( i/,)'1 **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY:eS . /fx?4, ) v �I i n xryf AUTHORIZATION NO. w OPERATION PERMIT BY: �4 DATE: 7 **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 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. 0 NAM ` DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) n PHONE NUMBER W -i�& 7* BDIVISION NAME LOT # DIRECTIONS TO SITE C9'��iULuaO�✓.Gy� ,U / J� �'�/C�X DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS "'J' NUMBER PEOPLE SERVED /7 TYPE WATER SUPPLY ( D SPECIFY PROBLEM OCCURRING DATE REQUESTED 09SZ INFORMATION TAKEN BY /`Y // This is 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. 1193 I DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME �a : v► �r-< c,�u, o n�Q PHONE NUMBER 7 ADDRESS 1$r 2 5' U,j-, Pass SUBDIVISION NAME_ �i lGs-u La,%ti (+ J u Q,,,,,_ n C_ 2 7 o a to // LOT # -3 DIRECTIONS TO SITE 7_v1+ Glii,a�«ou..S'� hrud.� .>.1• DATE SYSTEM INSTALLED 93 NAME SYSTEM INSTALLED UNDER �ob%z. Grca.,wooc� TYPE FACILITY i NO'L,- NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED TYPE WATER SUPPLY�Al y_ SPECIFY PROBLEM OCCURRING Nb Pyo IIe_ - – r, u k 4o &I o f -P- u.4- 3 3'e, :; [,;— 1 sil a,,.,.e d%4 tot) ` ) tom,. DATE REQUESTED - 1 'ir INFORMATION TAKEN BY 0V fti This is to certify that the information provided is correct to the best of my knowledge, and that I unders nd I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS (PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c *' Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name /1f9 6; Al /)- 17 L cryU nc.e — Date r- SO - �' � �� � � t'? ICY) Location Subdivision Name . L<, k r- Lot No. :) k -3 Sec. or Block No. Lot .Size q3n x 1,7'x 5?)',r .2 iA 1 'House —� Mobile Home _--_ Business — — — — Speculation No. Bedrooms — No. Baths — ���_ No. in Family — Garbage Disposal YES ❑ NO Fj�j- See F le F, < $ Specifications for System: Auto Dish Washer YES 0- NO ❑ Auto Wash Machine YES FJ, NO ❑ �cpy¢ Type Water Supply — ��� „i"u *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by ���*•� - 1 �'ik._ d 5� �dc.i �'�� 3 �i - y/r• f��! �,�� �,�„-,ate._ log 0 /33" Certificate of Completion C • vllw, c Date *The signing of this certificate shall indicate" that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. ii APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested 2. Address 160 6 :, 1j. (rl Y"e e/i Home Phone e/ � %''�� � 1/71 Business Phone , 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub -Division ee,,geo,4 la ke Sec. c), Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 123 06 /J•11".- - Bed Rooms_J Bath Room ` s � Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes urinals garbage disposal lavatory X showers washing machine d dishwasher sinks 'C' 8. a) Type water supply: Public '"' Private Community b) Has the water supply system been approved? Yes +' No - 9. o 9. a) Property Dimensions t b) Land area designated to building site ' �' � " 0 e p t. `°' w c) Sewage Disposal ContractorW/1; 4 I ,nS Pito, + -2opq r l n h ")° w°+ 3c! 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is corrgQt to the best of y nowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82)