1601 Underpass Road Lot 4AUTHORIZATION NO: 0794 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's 7 ,� P.O. Box 848
Name: f(.rf �'' Mocksville, NC 27028 Subdivision Name:
Phone #: 704-634-8760
Directions to propertyI6'1(' ,�''�� % LI R Section: iLot:
V AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Ro�dN!/: ZVipy401
�
**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 HEAL YH SPECIALIST DATE ISSUED
„ DAVIE COLNTY HEALTH DEPARTMENT
t _
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION'
„
;,P
ermi
Subdivision Name: ' V—
Directions to propeityl&y • / Section: % Lot•
--Tv RAPROVEMENT
' PERi T Tax Office PIN:#
Road Name:km�gz��Zip: '
**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/mstallation of a'system or the issuance of a building permit
OFT
with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERNff IS SUBJECT TO REVOCATION,IF SPfE
i p itr 6T PLANS OR THE INTENDED USE CHANGE YOUR - WASTEWATER -
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST•SEE THIS PERMIT$EFORE;
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �_ #,BEDROOMS #BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACHM TYPE # PEOPLE # PEOPLE/SHIFT ' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD), NEW SITE REPAIR SM,,wO'
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK' GAL. TRENCH WIDTH ROCK DEPTHa'Y LINEAR F!
y
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IUe
F
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BM
8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE #,IS (704)634-8760.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permidee's,_
Name:
Directions to property:
IMPROVEMENT
PERMIT
Subdivision Name:�',n"E �-
Section: Lot:
Tax Office PIN:# - -
Road Name: ` _ !" a�<' Zipt�L!l
**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 —:P # BATHS Q # 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 Fr../,,-) d
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
zfy I -_
rJ� IV
t�
�-�
d
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF 17PIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTAI LATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
r
SYSTEM INSTALLED
1
A-� OPERATION PERMIT BY:
AUTHORIZATION NO. 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)
13
DAVIE COUNTY HEALTH DEPARTMENT
%1% (Septic Tank) Improvements Permit and Certificate of Completion
(Gr6und Absorption Sewage Disposal System - G.S. Chapter 130 -Ar 4cle 13C)
OWNER OR CONTRACTOR J,/ U ii.' . ^-E_3 DATE PERMIT
A
LOCATION U 1982
/ S.R. NO.
SUBDIVISION NAME /.•Uc tt14 "AG LOT NO. SECTION OR BLOCK NO.
HOUSE ❑-`" MOBILE HOME E3 BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS —3 NO. BATHROOMS :G- Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO [a- Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES [r'— NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES i3"" NO ❑
SITE SUITABLE r YES ❑ NO ❑
SIZE OF TANKe, gal.
gal.,�t:,;?
NITRIFICATION FIELD:: sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public
IMPROVEMENTS PERMIT BY' �- r?(' ! �t t. �;�.c-(Q' INSTALLED BY
CERTIFICATE OF COMPLETION By A ` Date --7'
(8/16/73) *Construction mus• comply with all other applicable State and local iegltons
LOT AREA
B
�Y
1
yU
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
HOCKSVILLE, N. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME y.lIA (r./ DATE ISSUED
ADDRESS /d2,Y PERMIT NO. /9�Z
Explanation of charge /-
AMOUNT DUE /,S�-� SANITARIAN 9. ',/j
61
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.