1859 Underpass Road Lot 1 Section 2AUTHORIZATION NO: 0509 DAVIE COUNTY HEALTH DEPARTMENT'
'' Environmental Health Section PROPERTY INFORMATION
Perminde's�j -P.O. Box 848
Name: T1 ��3�� �)�- Mocksville, NC 27028 Subdivision Name: t3*%,1)6t_, x
V Phone #: 704-634-8760
Directions to property: i 5 ',� ti� ` Q I S Section: oc�j
, Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
a SYSTEM CONSTRUCTION
104
Road Name%R_6 Zip:7 Q nt'1
**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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST ',DATE ISSUED
�' .:����a�?33�' ""��*,'t�`r•P�+�P'iw�i�a sF T'��M'm"-kro+�.,�t'��4�'�t"rN�-^ S�y'11�����t�eg7�� �� r .=%r�^ � �� �
DAVIE COUNTYHEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMNTION
)?errrlItee' sA,f
Subdivision Name. ha:,: �.�k..ti t
Directions toPPe
ro rtY �«� r - ; .�.. ' '" + Section: Lot:
s .
r.
.:IMPROVEMENT
t
PERMIT Ta
x Office PIN:#
Road Name. * 1 4„ •- Zip. . Ib
**NOTE** This .ImprovementPermit 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/installatio i of a system'or the issuance of a building permit..
(Incompliance -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 PERMTY' BEFORE
INSTALLING THE SYSTEM, .
RESIDENTIAL SPECIFICATION: BUILDINGTYPE uSQ #BEDROOMS #BATHS #OCCUPANTS- GARBAGE DISPOSAL. Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS fINDUSTRIALWASTE: Yes or No
LOT•SIZE TYPE WATER SUPPLY �_ft '•DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS:: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH• ROCK DEPTH LINEAR FT, 13,
,. OTHER
REQUIRED SITE MODIFICATIONSICONDITIONS: `� ✓ U� +g
V uay.
IMPROVEMENT PERMIT LAYOUT Jr
14
l
•
1
' **CONTACT A REPRESENTATI OFTHE 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:
r.
DCHD 05196 (Revised)
r.
` „z
r ryy y aroT es"" lir h '7w*
DAVIE COUNTY.HEALTH DEPARTMENT
' iMPItOVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
.F'
=Perrltee's ,
Name. '� v" -a s Subdivision Name
b.
'�Dlrectionsto, prop
erty 1_ j, Section:- ct'on: Lot:
" t y IMPROVEMENT
4 ` PERMIT Tax Office PIN:# - -
.,A Road Name.,s Zip,
**NOTE* * This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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
w * '.,:,. `.; ,••,s PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENWIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
• INSTALLING THE SYSTEM.
RESIDENTIAL SP
ECIFICATION: BUILDING TYPE USS #BEDROOMS .� #BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or.No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No "
LOT SIZE r TYPE WATER'SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ;}
y
SYSTEM SPECIFICATIONS. TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT'y" $
,
OTHER v
REQUIRED SITE MODIFICATIONS/CONDITIONS: ` ' -- `= 1 ' 1 s7 d ep 1*9
I` x.
TMPROvEMENT,PERMIT LAYOUT
Z
• . _�� h
z
-
Ale
**CONTACT,A REPRESENTATI OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF
THIS SYSTEM _ ,I
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 RM. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704)634-8760. '
ti OPERATION PERMIT
SYSTEM INSTALLED BY: pct a p tom'
t.
A3
a-
AUTHORIZATIO p [�'�•h j a
N NOO � � ` OPERATION PERMIT BY: �raa'�rs,.c� . �'�• • c�:.�Za .�,. DATE:
THE ISSUANCE .. ..
** E OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE.
WITH ARTICLE 110 F G.S."CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS"; BUT SHALL IN NO WAY BETAKEN AS A'
GUARANTEE THAT THE SYSTEM WILL FUNCTION' SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
e
Ono,
Printed:Aug 04, 2015
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie,
North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or
inability to use the GIS data provided by this website.
-I- -')-►i
LJ - —
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAMEso
u
PHONE NUMBER
9W 4O �2
ADDRESS
\
%S `�
��-
SUBDIVISION NAME
Z'1�� PNCC 1 \X). (,\. nL_10OL LOT #,
DIRECTIONS TO SITE
\J5\_-'Xg a"
DATE SYSTEM INSTALLED \� 60'4T) NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 6v s'Q NUMBER BEDROOMSNUMBER PEOPLE SERVED—1
TYPE WATER SUPPLY � • SPECIFY PROBLEM OCCURRING w.mo. Q'r—
DATE REQUESTED-�� -� INFORMATION TAKEN BY v
This is to certify that the information provided is correct to the best of my knowledge, and t I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93