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111 Peace Court Lot 14` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ATC Number: 4282 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 FOR WASTEWATER CONSTFUCTION IS VALID FOR A PERIOD OF FIYE YE Environmental Health Specialist's Signature: late: CERTIFICATE OF COMPLETION j � **NOTE** The issuance of this Certificate of Com ion a system described on Improvement/Operation Permit has been installed in compliance wi a 11 a ter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NOW s a guar tee that the system will function satisfactorily for any given period of time. R f - Septic System Installed By: / /D Environmental Health Specialist's Signature: Dater. DCHD 05/99 (Revised) Account #: 990003813 Tax PIN/EH #: 5777-33- x82-44 Billed To: J & G Building Subdivision Info: Still Waters Lot # 14 Reference Name: Br;ao fpt;5,0je?' Location/Address: Proposed Facility Residence Propertv Size: see map ATC Number: 4282 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 FOR WASTEWATER CONSTFUCTION IS VALID FOR A PERIOD OF FIYE YE Environmental Health Specialist's Signature: late: CERTIFICATE OF COMPLETION j � **NOTE** The issuance of this Certificate of Com ion a system described on Improvement/Operation Permit has been installed in compliance wi a 11 a ter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NOW s a guar tee that the system will function satisfactorily for any given period of time. R f - Septic System Installed By: / /D Environmental Health Specialist's Signature: Dater. DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003813 Tax PIN/EH #: 5777-33-1382.14 Billed To: J & G Building Subdivision Info: Still Waters Lot # 14 Reference Name: Location/Address:27 06 Nd-ICWV 9015, Proposed Facility Residence Property Size: Tse m p `n <' ATC Number: 4282 **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 11 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 UNTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms #Baths Dishwasher: Garbage Disposal: 171� Washing Machine: 21 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats IndustrialWaste: ❑ Lot Size Type Water SupplyA Design Wastewater Flow (GPD) � lQ Site: New Repair ❑ System Specifications: Tank Siz/ &)—O— GAL. Pump Tank GAL. Trench Widt}I-4/—J Rock Depth 14 -1 -Linear Ft3CJ40 Other: Required Site Modifications/Conditions: 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.m. to 9:30 a.m. or 1:00 p.m. to 1:39 pim.�n the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: �/ Date: DCHD 05/99 (Revised) Deo 09 05 10:58a Charlie Jones 336-859-0607 p,p n. +.,.�....,IJ pAA dRlt lltU,U%T1D1bq),IIgi0iminrr immitil Tt AW, Dante County H"W) Department irov/mnmcvstb! Nau/Us Section P.O. nex 040/210 Hoapitol Stro•+t Iloc-:avillo, PC 2702-0 133Q751 -117G0 11110 PU-%FUTAN7--- T)15:: rU-PLICATION CWWr BZ MOCLLCGIla M MX -m; ALL T111 lU:110I11YU' YMINPRI A?ION XS rnt)YJ.DUD. Rotor to m. immwmArm SyTXX=4 tvr :notz-Aakions. 1. 114111141 to bn ")11,41 r.401lt7Ct rocr en M,L71. � Addrr11a S i 111a $hM..b+.la: L+f QCT_ no" rm" <<-/fu - :i-qo ��-�� at'fmL.L..mr l.,rwtiyfy�C NL +./7Ba3 Blurlcalls ►UG,UAl�7Q, a. Mare on t'.vw1t/AY'C LL 01;94C"t clow Alo—.._ M11111y Iddre.w CLty/st—Plp .� a. 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Pruperty Uittnullr.o: J n '� ¢ WRITE 0111=10KS lroon Mxkwole) to rIt01`Wf*rV:' 'Pat Ofntc I'Ml / r �` 3�-_.!__�' I t G 7 . QµyM'� --I v. eprrty nunrets: Lroau name 1 1 a �-_IT {- 1 t,ttyltJp A,�.1+Iii�e•c� •^�.�i'iJ/. b,)h'?o�' trill a Subdiril:0+1 provide iufornwtl«y as 11004tr3, N:nu.•: 5 TL.1„t, ir% !t 7l.J1S _ - — /�� 1 Lc> lien, 111ta•Ir• _ Lnl: Uatc Nome corners ftayL•rd: __ _ 7'bis is so cdtily /trail we gaordt11twn lur.nuu+ta W..wI1dwl t nm111CM11d 111111 Wly Oifulillil ct, revdeadnn, if nu site oriutendtd 1t)ti t6"Cr,er if 444 infnt+nllAon I.UUCIl ,lereafier are subject to SnSpcgs in. pL1.o lubsid0w, in this opplitalinn is N.'Metl dr iloinit,1. !.a/". Ju dltlnnnd /Ad/I Sol rrsimirsVe. Jer 0/144mrrew irsatrrc l/runt tdral4t) mrin— IhliAftail(!t(lYtal.IttifcbliGivr�onsenttotboAuUwr+rnlHrlu'titntYltl'CV�WeD�•laCc p. roirr ulmu 11mrr dmi-ilicil urYil4rty loealed in D.'. it County aims nrrneuby � e to cc nil 1,4;1 all ltsiint proredm'cs :.S netm.try (d ticicrudnc the site Snitallitit)•. SI:NAI'U1ik '171115 AR1„1 MAY DL USM I'UH UILAVYWG Mn.- PLAN (Include alt of Wo tulluwiug: )Srh[tnr good 9rDln••rd properly lutes ane tnitlotslons, s)r.tgw+u, +�.. w.w,, ...J..LU. L. u-•-1. _�---- Cltt lteYulr Charge CUadjJwlititatloul)wlt.:�� ;p -� JiCnCivcn_ ,.ArrntlnlNo..�-� Rt lfltll vCj 11) (051117 i voice No. --b:� / r 'd DULO 154 DCC 421 V~U4 r•lunoa +1 nep e 1 S t00 SO Co 040 Davie County Health D p'V j�E 1836 Environmental Healrim 3 P.O. Box 848 qsm' 210 Hospital Street O U 1 Courier # : 09-40-06 ENVIRONMENTAL HEALTH Mocksville, NC 2702h DAVIE COUNTY SSI-7C� Phone: (336) - 753 - 6780 Fax: (336) - 751- 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection . " "; 1� Name: OX1Ad N• MO -TV ►AJTI✓0— Phone Number 70¢•O(Home) Mailing Address: III 1 54 GE Co N � 11 (Work) ApVAIJ Com, Al G Z7009 Detailed Directions To Site: IF'4cM Mor-kSVILLE7 Go ! 4 C-4rr To ?of , $D) SvtiT4 F -V_ Atf A_aX- I M I1.E AAib-r*L4A.J C -CF r INTa 5"711-L- W.0'TE2, -r4v_T P-tr314T ov ry PcAr-r C.41�r 11-r 44,,,4,> ate! L.= -'F -r Property Address: III Pt. —4 - S •�.►� W a�t� 1 1.I 44�'t �r h�F 5771- 3 3 -12 b t Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: UE is RN)%_b). r7 Type Of Facility: kEs)4bE;4C' C440l� ri✓) Date System Installed (Month/Date/Year): 3 f Zo J Ok Number Of Bedrooms: _Number Of People: 3 Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any Known Problems? Yes V If Yes, Please Fill In The Following Information About The NEW Facility: Type Of Facility: G ARA GS Number Of Bedrooms: b Number of People Requested By: Date Requested: 6.3 ' 1 D (SignRurej For Environmental Health Office Use Only Approved isapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Paid By: Vait-a- fou Account #: .S!'z- 3 Money Order # Z.S'- 74 Amount: $_ /07 • 14 Date: G - .r ,, D Received By; Invoice #: 73 T a