140 Raintree Road Lot 26ORIZ?ATION NO: l 9ADAVIE COUNTY HEALTH DEPARTMENT -- --
Environmental Health Section PROPERTY INFORMATION
e.-ermittee's r P.O. Box 848
`"T�=f 1 icrJ I�,aC h 1 e Mocksville, NC 27028 Subdivision Name:- n
Directions to property: _ � �_-1 Phone # 336-751-8760 � Section: Lot:
*- rr AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
Road Name: gip:
**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 FonrdAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance., ith A7tMe )rl of G S Ehap er 110A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
n ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
ILI IS VALID FOR A PERIOD OF FIVE YEARS.
T DATEISSUED
.. a f r yi7 r� � —
�aN'
-'� - q,#DAVE COUNTY HEALTH DEPARTMENT
JMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
y e: Subdivision Name c n
Directr"ons" to Property: _ 1 Section: , Lot:
�a ti 'fit t ~da 1st T- EMPROVEMENT
PERIMH
Tax Office PINI,- -
Road Name: 41�~��,,� zrp:
f **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!rlqf,G,,Wmlei
on of a system or the issuance of a building perMit .
(In compliance with'., cue 1,30A, Wastewater Systems, Section .1900, Sewage Treatment and Disposal�ystems) ' �•
*"*NOTICE*.** THIS PERMIT LS SUBJECT TO REVOCATION IF SITE
t. i �;, PLANS ,OR' THE INTENDED USE CHANGE. YOUR`WASTEWATER.
ENVIRO _ TH SPECIALIft* DA ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
tom•. - INSTALLING THE'SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPESys # BEDROOMS 07 # BATHS '� ,�i� # OCCUPANTS'__!,�4_ GARBAGE DISPOSAL& No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT, #-SEATS INDUSTRIAL WASTE: Yes or No
l,oJ,,liK'
LOT SIZE 'TYPE WATER -SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE,
SYSTEM SPECIFICATIONS: TANK STLE • " GAL. - PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH (�' 1 LINEAR FT. t�
GTHER OTLC, T -ice - R�l•.AX-
REQUIRED SITE MODIFICATIONS/CONDITIONS:'
' 7
I IMPROVEMENT.PERMrrLAYOVT ROVED FILTER* *RISERt8> IF " FINISHED
15T 1tJ C,
45
TIE rte► Nodi C -i ^al
(r y 1 1 1 7u�S
To
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH -DEPARTMENT FOR FINAL INSPECTOEMM
YSTEM
BETWEEN 9:30.- 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # 7
OPERATION PERMIT.
. SYSTEM INSTALLED BY: 4 L -3H �T�
1 �iC PCZ '
- gaX . rrJ-STALK=p 5 L(Zo �p rJ LC i
7iF �1 Ti,J, JTL;eT "T
i 1> PtP&: 3t-0D60D o P
•AUTHORIZATION NO. 1: ` OPERATION PERMIT
DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT ESCRIB AB HAS BEEN INSTALLED. COMPLIANCE
WITH ARTICLE 1 I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL. STEMS", BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE'SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
1x11D 05/96 (Revised)
• -Qc�(A1%6 lON FOR SITE EVALUATION/IMPROV'. HENT PERMIT & ATC
Davie County Health Department
} Environmental Health Section
�^ t4 P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
** IMP THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the I�N�FORMATION BULLETIN for instructions.
1. Name to be Billed)�Lj Contact Person
Mailing Address Home Phone
City/State/ZIPAJ`/14JYe� d(7. 2704'
Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation Improvement Permit/ATC Both
4. System to Service: X House ❑ Mobile Home ❑ Business 11 Industry ❑ Other ,
5. If Residence: # People 2 # Bedrooms 7` # Bathrooms /2—
Dishwasher
ZDishwasher ,�i //
Garbage Disposal /Washing Machine 11Basement/Plumbing Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1KNo
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS (from Mockkssjville) to PROPERTY:
Property Address: Road Name h
-hAhYt~ L'ST��,76 $O �ilGc.c�
City/Zip �O d
If in a Subdivision provide information, as follows:N
Name�a' i - T ree-e_ 1
Property Flagged:
Block: Lot: 6 Date Pro a Fla
Section: p
This is to certify that the inf(frmation provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site i 'tabYtity,,
DATE G SIGNATURE r
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the fallowing: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations). '
i� ,
����� ��� �Qi� ;Z0%Y�� Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Revised DCHD (07/99)
Account No.
Invoice No. % - 3
.1 DAVIE COUNTY HEALTH DEPARTMENT
�.
+►- �" (Septic Tank) 'Improvements Permit and Certificate of Completion
(Ground-Absor-pticm.,Sewage Disposal-System' G,.S.`*Chapter "130=Artii: le- 143C),'
OONER OR CONTRACTOR DATE ;�' .e��'. PERMIT
LOCATION-18'67-
S.R. NO.
SUBDIVISION NAME 'tt.'tG➢ & LOT NO. SECTION OR BLOCK NO.
HOUSE ❑" MOBILE HOME BUSINESS ❑
N0. BEDROOMS �'- NO. BATHROOMS House Trailer 800 Gal.-.' 400 Sq. Ft.
T Two Bedroom House 800.Gal 600 Sq. Ft..
GARBAGE DISPOSAL UNIT YES ❑ NO �''Three .Bedroom House 900 `Gal. '900' Sq.: Ft.
AUTO. DISHWASHER YES NO ❑ Four Bedroom House, 1000 Gal. 1200.Sq.,Ft.
AUTO. WASH. MACHINE YES EP NO
SITE SUITABLE rY YES NO t
SIZE OF TANK gal.
NITRIFICATION FIELD jsq. ft. x
,,. 4v x
DEPTH'OF STONE IN LINESs
wtrry. i
WATER SUPPLY: "Individual 13 Public' ❑��� " .
j'ti.�:���� INSTALLED BY
;IMPROVEMENTS PERMIT BY T- A&�:
CERTIFICATE OF COMPLETION By Date
(8/:16/73) *Construction must comply with all other-applicable State and locaV regulations
LOT AREA : r�
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_ DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27023 \ �
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME `��� DATE ISSUED A3 1S
ADDRESS PERMIT NO.1967
Explanation of charge
AMOUNT DUE /�,- SANITARIAN
PLEASE REMIT THE ABOVE A14OUNT ON RECEIPT OF THIS STATEIIENT.