112 Mockingbird Lane Lot 95-97r t ick '. ' `i a v �,v- - }, i � - - � ;• sxr '• ,.. a,� l S: •. , r, 'i...'av
.v ,�.r'6��isj�yri$'�" '1�'v1=`•-t�`t¢ z�_ r ya ^ � t,'F,:`d`... sr v: •J -.Y /'"y :r' ..11 • *''t* j Y`:.� ,S"_,°.t"t-';'.,;.y'.tz r �dn,,.T�v r �"�` .- Q
Permittee's ! AVIE COUNTY HEALTH DEPARTMENT
,r/ .
i Name:t .>�it Environmental Health Section PROPERTY INFORMATION
�?.
P.O. Box 848
D tions to roe �"�°'S . ��Z ✓ t ` 41
P P rtY� • Mocksville, NC 27028 Subdivision Name:
t"?, Phone #: 336-751-8760 ` of 7
+ /1' '�t��1 t' 1",. -;Section: Lot: �J
o' AUTHORIZATION FOR
WASTEWATER Tax Office PIN:11�7/ 9 - YI OL %
•, SYSTEM CONSTRUCTION _/ M
AUTHORIZATION NO: 00256t ', ".A 112 D /,(f00U oad Nam�t'" � +1 �i ��C Zip•�
**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.
corn Fliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
-`***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
%S IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTHSPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS -.2.-- # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) � NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE -'GAL. PUMP TANK/UOI%GAL. TRENCH WIDTH `.T � ROCK PTH LINEAR FTS+
OTHER //I�1 /✓ G� ` !
As stated In 15A NCAC 1I3A.1969(5)
REQUIRED SITE MODIFICATIONS/CONDITIONS: �(iied_s BMs rnmo
IMPROVEMENT PERMIT LAYOUT
4
r
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M ON THE DAY OF INSTALLATION. TELEPHONE -i IS (336) 751-8760.
OPERATION PERMIT c y,
SYSTEM INSTALL B iG•'On/�/�
7 .•
•.t
f, 0
it ..
AUTHORIZATION NO ' ERATION PERMIT BY: DATE: r
'*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE,THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 7 (Revised) 7 3n 1 1
DAVIE COUNTY HEALTH DEPARTMENT
-"(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR 0-),'C. �'� � � ��: DATE PERMIT
LOCATION t- . ! 3 i , Zi 1 ;�U ; ': 3 �,. - . t r.., c', `J`�n. 7. L c ,� - �t� N9 1619
r 1 to
t-�y%L-d-+ C, P- <-,-t U-kt 4.. z, r S.R. NO.
SUBDIVISION NAME LUC)")� 14"1 LOT NO. SECTION OR BLOCK NO.
NO. BEDROOMS
GARBAGE DISPOSAL UNIT
AUTO. DISHWASHER
AUTO. WASH. MACHINE
SITE SUITABLE
SIZE OF TANK
NITRIFICATION FIELD
OME U BUSINESS
NO. BATHROOMS -
YES ❑
YES ❑
YES
YES ❑
gal.
_/--_`-.
NO ❑
NO ❑
NO ❑
NO ❑
sq. f t.
DEPTH OF STONE IN LINES: f
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY i Ar` -='0:1 1
CERTIFICATE OF
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom House 800 Gal. 600 Sq. Ft.
Three Bedroom House 900 Gal. 900 Sq. Ft.
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
r
INSTALLED BY
By Date "moo/ / /
(8/16/73) *Construction must comply with 1 other applicable State and local regulations
LOT AREA
G � f a Ua o
D.
,
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
'
NAMEt 1. , 12. DATE ISSUED
C L- 4
ADDRESS =l�C�-,mo -�. PERMIT NO.
Explanation of charge
AT4OUNT DUE % SANITARIAN 2a,
� by
�, PLEASE REr4IT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.