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Perniittee's ./ _ DAVIE COUNTY HEALTH DEPARTMENT i
Name:-. Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 f
Dkecti ns to Prope / r+'" /rr ` T Mocksville, NC 27028 Subdivision Name: it /l�Qt�i
Phone #:.336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION q -
AUTHORIZATION NO: 002671 A RoadqNare�in#4 Zip: 270M
**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 Permiis.
(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
RESIDENTIAL SPECIFICATION: BUILDING TYPE,_ /Y- # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL, WASTE: Yes or No
LOT SIZE - TYPE WATER SUPPLY 1 Z, DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE �-
SYSTEM SPECIFICATIONS: TANK SIZE
REQUIRED SITE MODIFICATIONS/CONDITIONS:
GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
IMPROVEMENT PERMIT LAYOUT
171,
F;
ro OT,
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT -
tSC� t Su�D LIP,
CIT
SYSTEM INSTALLED BY:
Pi T (,onlN�zus � •
Sr Z I.I rJ �L� r
AUTHORIZATION NO.2(O'AA- OPERATION PERMIT BY: DATE: 12-toIola
"TILE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS ESCR ABOVE 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 M402 ) #6#10- V01— --aU6 jee0 5%-7
Permittee's ;
DAVIE COUNTY HEALTH DEPARTMENT
Name; -.- "' -..lf l /�A,�.
f1 Environmental Health Section
PROPERTY INFORMATION
P.O. Box 848
Directions to property:. f
Mocksville, NC 27028
Subdivision Name:
/
-. -- -
Phone #: 336-751-8760
Section:
-Lot:
-
AUTHORIZATION FOR'
-
WASTEWATER
Tax Office PIN:#
-
SYSTEM CONSTRUCTION
�%
�P"-d
/-
AUTHORIZATION NO:
002671 A
Rbaftan(i fell)
Zip: 27000
"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
RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS # BATHS*;' # 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 GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
1
I
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT/ n\ ,1 �{ I J I
SYSTEM INSTALLED BY: T - t i , It 1 � i -C,
Uv
J
AUTHORIZATION NO. OPERATION PERMIT BY: \ i / `- /fes DATE:
'.�` /•� �! �`
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS�EEN 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.
DCHDoz/OZ(Revised) . /W / 1dl �%U ,/r`` �U()
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER Wk-6-71�
ADDfid
REES,S/L/ l A H11V11G� (,UL ir-SUBDIVISION NAMEl�%�Va Ai C e, &-a xe 6 LOT #
DIRECTIONS TO SITE-��7`4 f /0 01 &�OuW p4 D (rr kift
91, !R®l Sda lh iiA/Tee p Av if
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER J�IJ
TYPE FACILITY NUMBER BEDROOMS_ NUMBER PEOPLE SERVED
TYPE WATER SUPPLY D SPECIFY PROBLEM OCCURRING Ned
T u kledup7ue.�' "d&1V a:�
DATE REQUESTED �'� �V "(f �' INFORMATION TAKEN BY
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. 1/93
r
AUTHORIZATION NO: 1-1 DAVIE COUNTY HEALTH DEPARTMENT
�7_- Vxn
Environmental Health Section PROPERTY INFORMATION
Permittee's - r " P.O. Box 848 �y
Name: �' ,'� f ' Mocksville, NC 27028 Subdivision Name:
i, Phone #: 704-634-8760
Directions to property: '.>' ;` Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Qffice PIN:#
SYSTEM CONSTRUCTION / g - -�
Road/ Name: / le Zip: ,--2,17 i • V
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEALTH SPECIALIST
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BED ROOMS #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 GAL. TRENCH WIDTH <�"` ROCK DEPTH LINEAR FT.
OTHER W 4
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
i'
e;
"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
AUTHORIZATION NO. .OPERATION PERMIT BY:
�YV&lM 3VIIZ& IV.11004073ii
i'X3y;2dl- 14•''
DATE: /1-174;7
;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 AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
• .. :r- O
AUTHORIZATION NO: i� 040 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's ��'"(""" P.O. Box 848
Name: �1%1'/R :, Mocksville, NC 27028 Subdivision Name:��.
J
Phone #: 704-634-8760
Directions to property: Section: �% Lot:
AUTHORIZATION FOR
WASTEWATER TOffiice PIN:#
ax
SYSTEM CONSTRUCTION / 1 - -
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)
'""NU11UE* Y111JAUIHUK1ZA11UN P'UK WAII'KWATEK CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
-� DAVIE COUNTY HEALTH DEPARTMENT f
F
' 4 IMPROVEMENT AND OPERATION PERMITS' PROPERTY INFORMATION
0-1
Naft"1e , ' Subdivision Name:',`ff%�
Direct9ns to property: �,' f Section: % Lot:
a -• EgPROVEMENT
PERMIT Tax fifice PVN:#
Road Name:/rV_rr'eZoip:
**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 y # BATHS _' # 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 Z— f
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH+"" ROCK DEPTH p�� — LINEAR FT.
OTHER 1 ! r a_l
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT t ,
7L
uvy�.
lo�S
**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:
C.;:�:11 L
AUTHORIZATION NO. _/04/ OPERATION PERMIT BY: eiW DATE: /f -17-`%
"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 05N6 (Revised)
' DAVIE COUNTY HEALTH DEPARTMENT
.` -S IMPROVEMENT AND OPERATION PERMITS' PROPERTY INFORMATION
Permittee's
Nairne. � �� ' •f �i �1 % :
,. Subdivision Name: �'�}, �, ✓t°� ���...
Directions to'property: Section: J Lot:
IMPROVEMENT
PERMIT Tax tO five PIN:# - -
,Road Name: %/fN r /=.- �Zir: t V r 1)
**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 --# OCCUPANTS ~GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
L'OT 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.
OTHER � f��3.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
N
"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: _
71/ 1 -
AUTHORIZATION NO. &�&- OPERATION PERMIT BY: DATE: // -171 4V
**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)
r
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME PHONE NUMBER
ADDRESS i1 4a4��� SUBDIVISION NAME
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
SUBDIVISION LOT #
-s
DATE REQUESTED INFORMATION TAKEN BY