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241 Westrige Road Lot 18AUTHORIZATION NO: 0635 DAVIE COUNTY HEALTH DEPARTMENT r 'R` Environmental Health Section PROPERTY INFORMATION Perrnittee's/% / P.O. Box 848 Name: / ee � i r ,rr'/7- [ Mocksville, NC 27028 Subdivision Name: �/r��I'/© Phone #: 704-634-8760 Directions to property:G�'f -� e Section: / Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION �e: 7 v o Road a 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 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 DAVIE COUNTY HEALTH DEPARTMENT 11WROVEMENT AND OPERATION•PER11vM PROPERTY INFORMATION ', o ' Name u .a* .%: i. Subdivision Name: i w Do property: f ,�`r 1v Vii' Section: / Lot:RdPROVWWENT P +\ , Tax Office PIN:# - Ro id ar1e. i eZ` pp::07004 !"NOTE"i 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 constiuctionAnstallation of a system or the.issuance of a building permit. :(Incompliance with Article 11 of G.S. Chapter 130A, Wastewatei Systems, Section .1900 Sewage Treatment and Disposal Systems) r i***NOTICE*** THIS PERMIT is SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THLS PERMIT BEFORE ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.s , RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS'_ # OCCUPANTS ,? GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: VACUITY TYPE: # PEOPLE #PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE ' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)NEW Sm.REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK •" GAL. TRENCH WIDTH ROCK DEPTH�;21L LINEAR FT.; 49D OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: "CONTACT A REPRESENTATIVE OF THE DAME COUNTY HEALTH DEPARTMENT FOR FINAL INSPEC'T'ION 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) 6348760. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pertfdttee's ) Name: Subdivision Name:` aDirections to property: ! Section: Lot: tf IMPROVEMENT k° PERMIT Tax Office PIN:# RoadName: , **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_ t� # BATHS # OCCUPANTS ,�F_ 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 WIDTHROCK DEPTH, -..,". LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "*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: R AUTHORIZATION NO. OPERATION PERMIT BY: Akl' 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 APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAM r. DIRECTIONS TO SITE & PHONE NUMBER %Y%" Co.0 to SUBDIVISION NAME' ' LOT # DATE SYSTEM INSTALLEDqZ/-Z-2/22Y NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS '--? NUMBER PEOPLE SERVED TYPE WATER SUPPLY 4 SPECIFY PROBLEM OCCURRING DATE REQUESTED &XV 1 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. 1/83 DAVIE COUNTY HEALTH DEPARTMENT (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C) OWNER OR CONTRACTOR t_ + « . _ a Y. l<.. , . ��a. DATE 2 %' %/ PERMIT LOCATION 1674 S.R. NO. SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO. HOUSE (0' MOBILE HOME ❑ BUSINESS C NO. BEDROOMS I NO. BATHROOMS 2 GARBAGE DISPOSAL UNIT YES ❑ NO ❑r AUTO. DISHWASHER YES ❑' NO ❑ AUTO. WASH. MACHINE YES ®" NO ❑ SITE SUITABLE YES NO ❑ SIZE OF TANK gal. NITRIFICATION FIELD sq. ft. DEPTH OF STONE IN LINES: WATER SUPPLY: Individual ❑ Public IMPROVEMENTS PERMIT BY `'•x.»._.� �� = >>;r House Trailer 800 Gal. 400 Sq. Ft. Two Bedroom House 800 Gal. 600 Sq. Ft. Three Bedroom House 900 Gal. 900 Sq. Ft. Four Bedroom House 1000 Gal. 1200 Sq. Ft. INSTALLED BY 1_ •7.; CERTIFICATE OF COMPLETION By a- • ��- t'+ Date (8/16/73) *Construction must c ply with all other applicable State and local re u ations LOT AREA s:��'.1 S? •iF:. n� DAVIE COUNTY HEALTH DEPARTMENT P. 0. BOX 57 !�\ HOCKSVILLE, N. C. 27028 (704) 634-5985 Statement for Septic Tank Improvement Permits and/or Site Evaluations NAME , ,�, (:�. � ,.�,. �n � DATE ISSUED ADDRESS <'1 .; ;'�� "� PERMIT NO. f . Explanation of charge `� —acs • • �L�s� AMOUNT DUE SANITARIAN PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.