149 Dogwood Lane Lots 150-153Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
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(Issued in compliance with Article 11 0
11145, G.S. Chapter 13OA, Wastewater Systems)
***This Authorization Far 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.***
_—,-', AUTHORIZATION NUMBER
NAME �� ��/err f S DATE
NAME ON IMPROVEMENT PERMIT (If different than above`)
SITE LOCATION �.t��dP��j�/��Y — �r A09 WD o CL 472- -
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**#NO'TICE*" THIS AUTHORIZATION FD WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONENTAL HEATIKSPECIALIST DATE
DCHD 10/95
: DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
':IMPROVEMENT PERMIT
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**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 6.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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NAME ,��/sl�v1 �r�s� � i PROPERTY ADDRESS Na oa� �%t • ~ DATE
LOCATION
SUBDIVISION NAME e' 0 LOT NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE +�_y / i'�`�f# BEDROOMS 3
SEC./BLOCK NUMBER
# BATHS # OCCUPANTS S GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL. WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH LINEAR FT. `� V
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OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
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IMPROVEMENT PERMIT BY/
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FILL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON�JHE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
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OPERATION PERMIT
SYSTEM INSTALLED BY
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AUTHORIZATION NO. .Z OPERATION PERMIT BY /V� DATE S
**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 IRA, 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 10/95
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMP DENT ERMIT j
ro n eri' DOES NOT authorize the construction or installation of a septic tanks stem or any wastewater
�' ✓ yst, �:�r�1 RUTH TION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
: 1e)(, gor�.trucf0n/0staP, tion of a system or the issuance of a building permit.
n compliance with Article fl of G.S. Chapter 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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NAMEi/�I.'z�! /�rf� , C PROPERTY ADDRESS Naa 3410e CL �-x DATE
LOCATION
SUBDIVISION NAME LOT NUMBER SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE BEDROOMS -7 # BATHS # OCCUPANTS _:K�' GARBAGE DISPOSAL.: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE Gr'•
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL.. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER M.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST,
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. x
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IMPROVEMENT PERMIT BYPail /
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FILL INSPECTION OF THIS SYSTEM.BETWEEN
B-30-9:30 A.M. OR 1:00-1:30 P.M, ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
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OPERATION PERMIT SYSTEM INSTALLED BY
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AUTHORIZATION NO. 3.Z OPERATION PERMIT' BY DATE
**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 "SERE 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 10/.9
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) r r/
NAMEA: Ila APq IS Me, PHONE NUMBER l��J ---0
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ADDRESS ��I �oC��,��� OL ��� SUBDIVISION NAME
lip5.,7) LOT #
DIRECTIONS TO SITE 15q
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DATE SYSTEM INSTALLED �Z`z�`-` NAME SYSTEM INSTALLED UNDER 1 k-omg � (/�►`(�
TYPE FACILITY QS)� NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLNQ-'�12SPECIFY PROBLEM OCCURRINGi
a 0-4-1.
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understanda� i responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT I 1 LWIA C- .
Rev. 1/93 A Ln'l,, 00
DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treat ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name //?f?%/1 �i%�„�/ /%`��=-, iii-�%��'� /Date �1// /�� NO 137
Location ��/��i�� lI�i�✓1 r c� �� rsi-'f
Subdivision Name Oo Lot No. _ Sec. or Block No.
Lot Size
No. Bedrooms --p
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
House Mobile Home
_ No. Baths No. in Family
Y NO '
Business Speculation
ES ❑ fl Specifications for System:
YESNO C)YESj NO ❑C' ���� lc%�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by (x,
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*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 4��6�
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Certificate of Completion Date AZ2-1Z /TV
"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.
DAVIE CO1WTY HEALTH DEPARTMENT
J� 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 / z;1! ,f� �% %/�� /21 Date N2 0
Location
Subdivision Name `7�0 �,-� �- Lot No. Sec. or, Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms �-'7 No. Baths No. in Family_
Garbage Disposal YES p NO p- Specifications for System:
Auto Dish Washer YES q NO p
Auto Wash Machine YES [V NO 6[:� �3 _A'
Type Water Supply
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*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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
Certificate of Completion Date 1L�22
"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.