143 Westridge Road Lot 30•,
AUTHORI7,ATION NO: 1424 DAVIE COUNTY HEALTH DEPARTMENT ( _
Environmental Health Section PROPERTY II FOKIGIAT; ON
Permittee'sP.O. Box 848
Name: �'`'�t SMn, Mocksville, NC 27028 Subdivision Name: U')e.S:T aioC' 5
Directions to property: � � � � �� 1S Phone #:704-634-8760 B
Section: Lot: = -'"�
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
I SYSTEM CONSTRUCTION
0�.1 Road Name: 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.
(In compliance with Article 11 of QS. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�...:._ _
***NOTICE*** / NOTTCE THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
61 AC" �^ �� �` IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRdNr4E1vV"I•AL HEALTH Itt6iNfIST, DA
PAVEE COUNTY HEALTH DEPARTMENT
y . �• IMPROVEMENT AND OPERATION PERMITS PROPERTY ATION
r :Permittee'sxf,
. Name. ''t' `M? �N• Subdivision Name: ��1y.ko4SZ5Y
^Directions to Property: I .;x a I�. Section: Lot:
RdPROVEMENT
C, ARS 9P
Tax Office PIN*
,rA "ijbv4 O QARoad Name:4 ;S;T" !p:'
"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 De nt prior to the
constcuctionihnstallation of a system or the issuance of a building pemrit �, "
(In compliance with Article 11 of.G.S. Chapter. 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
`t
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE PMMED USE CHANGE. YOUR WASTEWATER
ENVIIiO AL HEALTH T, DA ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
.t INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE Ot # BEDROOMS 3 # BATHS Z ' # OCCUPANTS -(0 GARBAGE DISPOSAL Yes r o
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZEr2P�TYPE WATER SUPPLYC�7M7 DESIGN WASTEWATER FLOW (GPD)G! NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH � f ROCK DEPTH �K •, LINEAR FT. �8
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: �� �,►t �� • KAT'
"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.
W3 X/if
AUTHORIZATION NO.- / OPERATION PERMIT BY DATE:
---
"TiIE 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 O5/% (Revised) . ti
DAVIE COUNTY HEALTH DEPARTMENT L
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
.Name: Subdivision Name:
Directions to property: XSection: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name i fi b.x' < Zi,
p: W.
**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
v INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE L1L5-# BEDROOMS # BATHS Z # OCCUPANTS GARBAGE DISPOSAL: Yes r No
COMMERCIAL SPECIFICATION: FACILITY TYPE ,# PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE I� t K 2� TYPE WATER SUPPLY (_k n�`I DESIGN WASTEWATER FLOW (GPD) Z--C45Q NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH -LINEAR FT. C='
Y OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: � ► I%k='#"f'C � >
y
tI_
`
*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: �✓� Pit°n'Yv°r .Y��/Y-
4,
r
r
I r
r
AUTHORIZATION NO. - �=�- 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 "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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME TE'_►�/'/ / �[Ossmah- PHONE NUMBER
ADDRESS_��� Lt�eSJ��I �- 1 fid- - SUBDIVISION NAME �.t'J� . •Q �J2r
�✓ 16106 SUBDIVISION LOT #
DIRECTIONS TO SITE 1a Y , 5e -S- 61-72, &.A,0aZxQ Cl - 9V7��C'�-�
=Y .
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UND
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED CD -y/d- 7
/-a4-,L/ T -Le- -
� -b C., � "oC -1
NFORMATION TAKEN BY
DAVIE COUNTY HEALTH DEPARTMENT
(Septic. Tank) Improvements Permit and Certificate, of - Completion
.:'(Ground Absorption Sewage Dispoppsal:_System - G.S. chapter. 130 -Article 13C)
OWNER OR CONTRACTOR DATE PERMIT
LOCATION
1338
ti
S. R. NO.
SUBDIVISION. NAME ' 'a �;, - `LOT NO. 30- SECTION OR BLOCK NO.
HOUSE MOBILE HOME 0
BUSINESS ❑
�'
House Trailer, 800 Gal. 400 Sq. Ft.
N0. BEDROOMS + NO. -BATHROOMS
'i Two Bedroom House'' 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES, ❑
NO
Three' Bedroom, House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES2'7,,NO
Q
r Four Bedroom House'' 1000.Gal. 1200 Sq. Ft..
AUTO. WASH. MACHINE YES
:NO ❑
yq;.i�w�
SITE SUITABLE YES-
NO ❑
SIZE OF -TANK 4W, gal'.
+i'i`rrrii► .b�►,
NITRIFICATION FIELD
sq.-ft.�}
DEPTH OF STONE IN. LINES: .2-4c,
5
AAMP Hier
d�`e
.WATER.SUPPLY: Individual]
Public []
-IMPROVEMENTS PERMIT BY
INSTALLED BY
;CERTIFICATE OF COMPLETION
BY.:
Date B
16/73).'.;*,Construction must
.omply with all
other applicable State and local regulations
IAT- AREA ;1A �X a?a jo'
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