138 Westridge Road Lot 38Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
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P.O. Box 848
210 Hospital Street
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Courier # : 09-40-06
Mocksville, NC 27028
Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement emodeling Reconnection
Name: AG& Vl S A Phone Number (o 76 3 — 19'cl I (Home)
Mailing Address: e- / O O 0 -e-J 9 3 3 G- 'I 11 — -7 31 7 (Work)
-ree,..� $ v ►r O N L Email Address: Cr, S 1 e. Po r 0.9f a S v4
Detailed Directions To Site: LX^J ARLC-OC1S S
O NJ �
Property Address: ?j g We S +r I d jL�- Yz-Avi A 1/,,, N C e
Please Fill In The Following Information About The EXISTING Facility: �a�J
Name System Installed Under: ( U oc (+ e I Type Of Facility:
Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: 2
Is The Facility Currently Vacant? Yes 6;) If Yes, For How Long?.
Any Known Problems? Yes P If Yes, Explain:
Please Fill In The Following Information About The NEW Facility: .
Type Of Facility: `j- C.ve2►J ,r ch O.J De CIL • Number Of Bedrooms: Number of People
Pool Size: G age Size: N 1A Other: N
Requested By: �� W - Date Requested:
(Signature)
For Environmental Health Office Use Only
LAppr,oved Disapproved
Comments:
Environmental Health Specialist C�ffj'96�����.2��C Date: 16 — 21 �
*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
Payment: Cash Check Money Order #
Paid By:_
Account #:
Received By:_
Invoice #:
for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE:. Issued in Compliance .with o.S.-of',North Carolina Chapter 130 Article 13c i
:. Sewage Treatment and Disposal Rules (10 NCAC 1 OA .1934-.1968) :.
Permit Number
Name Date NO 3911
Location �i'�.r �-i�- U.� /fr.�
Subdivision Name tot No. Sec. or Block No.
Lot Size HouseMobile Home _ Business Speculation
No. Bedrooms _.— No. Baths —_ No. in Family_
Garbage Disposal YES -E) NO'. Or ;Specifications for System:
Auto Dish Washer YES NOS ❑
Auto Wash,Machine YES
NO .
Type Water' Supply
'This. permit Void if.sewage system described below is not installed within 36 months from date of issue.
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=�� t
Certificate of Completion Date �8s
'.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`systegwill function
satisfactorily for any, given pe-riod of.time. ;
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.
Permit Number
Name Date
Location —
Subdivision Name Lot No. Sec. or Block No.
Lot Size _ House Mobile Home --- Business _— Speculation
No. Bedrooms No. Baths — No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES Q NO ❑
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
t
i
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 —
*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 COUNTY HEALTH DEPARTMENT
IMPROVEMENTS .PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name / 1PAa Date /s`� # 2768
Location __5,1y4 ll��/-r'� r.�! AL �'�u ��,� t� . �C %' �' � ✓ f'
Subdivision Name!/���-
�!� �'
Lot No. Sec. or Block No.
Lot Size .✓!-4�t5
House
Mobile Home _ Business Speculation
No. Bedrooms
�--No.
Baths
No. in Family
Garbage. Disposal
YES
0 NO p
Specifications for Syste
. Auto Dish Washer
YES
NO p
Auto Wash Machine
YES
(] NO C]
Type Water Supply
*This
not 36 from"!da o issue.
permit Void if
sewage system
described below
is installed within
months
�(Dtprovements 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 RM. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
U
Certificate of Completion " Date
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.
y
DAVIE COUNTY HEALTH DEPARTMENT
(Septic- TankY ;Improv'ements Permit and, Certificate of Completion
Adround Absorption Sewage Disposal System G.S. Chapter 130 -Article 13C) 72
OWNER OR CONTRACTOR- DATE PERMIT
ON 1326
LOCATION
S.R. NO.
SUBDIVISION NAME WvS1r_:#Acj&, C5'6iv-S, LOT NO. 39 SECTION OR BLOCK NO.
HOUSE MOBILE HOW C3 - BUSINESS [3
NO. BEDROOMS NO. BATHROOMS Y2.
GARBAGE DISPOSAL UNIT YES 0 No ❑
AUTO. DISHWASHER YES NO [3
AUTO. WASH. MACHINE 'YES COr NO [3
SITE SUITABLE YES OR( -NO Ej
SIZE OF TANK,
NITRIFICATION FIELD. S4. ft.
DEPTH OF STONE IN LINES:
WATER Public
.SUPPLY: Individual 0"
�IMPROVEMENTS,PERMIT,BY
House Trailer 800
Gal.
400 Sq. Ft.
Two Bedroom House 800
Gala
600 Sq. Ft.
Three Bedroom House 900
Gal.
900 Sq. Ft.
'Four Bedroom -House 1000
Gal.
1200 Sq. Ft.
A4
INSTALLED BY
CERTIFICATE OF COMPLETION
ByDate 4121'
<8116/73), *Construction must1,'ply with all other' 'applicable.State and local lrejulations
LOT -AREA -
S
1z:14 3
T -f W* 4-
d: "Svaw
1600*114VO
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