248 Westridge Road Lot 51.�:., .r .: �oC.=, c....�:1-.�. � ?�,y.. -�Stti �",f:;•:�y,yr •.r _.:.n.�,;.�--+':,r=rti',; sr"`_.i-"rr���%~A.taa,.�fi,'`�r``� ��i�`r`�';y.�-�a..r:u:�'$:da[.+d=�.i.:..�:3.s�:+rw..x.:.-,x--�sr-+-�-'*'_`-� ------n•`"'�''-�f7
Permittee's _ y "" DAVIE COUNTY HEALTH DEPARTMENT_
Name: 4lf""� ,;� Enyironmental Health Section PROPERTY INFORMATION
6,, r / P.O. Box 848
Directions to property.: try •. Mocksville, NC 27028E Subdivision Name: Wied,
s•�{��! f� �
Phone #: 336-751-8760
f Ms. r,. Lot:
91 AU�fHORiZATION FOR Section: 1
y�! ,4',r *ASTEWATER moi, f _ (,,,• j '
Tax Office PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION NO: 00 9:7 1 A Road Name: Zip�27
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
y ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST' DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 5F .# BEDROOMS # BATHS. # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
1 0.
LOT SIZE TYPE WATERS PPLX V DESIGN WASTEW TER FLOW (GPD) L/ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE (+ - GAL. PUMP TANA '"C GAL. TRENCH WIDTH 6 ROCK DEPTH V tLMEAR FJT.
Lt ! 1-13/"� �!
rG44
OTHER f As stated in 15A NCAC 1 RA i oaore, E r
REQUIRED SITE MODIFICATIONS/CONDITIONS:
F
ROVEMENT PERMIT LAYOUT
J"u OWN
. ' (+c'`�
�
� Pl �
v �
r �
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN $:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
fic SYSTEM INSTALLED BY: Ar SD C.t
}
Cp
Li-&��IMXC ►3'�0
AU1 RO TION 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 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.
**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 F'orm/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/ y IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE j. # BEDROOMS I/ # BATHS ` " # OCCUPANTS L' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE. # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE V TYPE WATER SUPPLY• {" DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE '-
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH '' ! ROCK DEPTH._r i 'LINEAR FT.
,r
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
a
i
IIFOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT
E
4
i
SYSTEM INSTALLED BY:
e.�
r jr�
f
N NO. OPERATION PERMIT BY:iJ DATE:
AUTHORI Z ATIO .'
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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 02102 (Revised)
1,
.�i'
t
`� DAVIE
COUNTY HEALTH DEPARTMENT '
_Permiftee's
' Name: �✓+ ' .
/ /�' .�i %`
Environmental Health Section
PROPERTY INFORMATION
P.O. Box 848
Directions to property:
Mocksville, NC 27028
Subdivision Name: �V���//06I-''
Pfione #: 336-751-8760
Section: Lot: * i.
AUTHORIZATION FOR
-
- WASTEWATER
Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002 971
A
Road Name:
**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 F'orm/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/ y IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE j. # BEDROOMS I/ # BATHS ` " # OCCUPANTS L' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE. # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE V TYPE WATER SUPPLY• {" DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE '-
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH '' ! ROCK DEPTH._r i 'LINEAR FT.
,r
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
a
i
IIFOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT
E
4
i
SYSTEM INSTALLED BY:
e.�
r jr�
f
N NO. OPERATION PERMIT BY:iJ DATE:
AUTHORI Z ATIO .'
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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 02102 (Revised)
"r5 �,i,^^•R.-.—�
,3.
,.. r `1.� r,'i,� tii, 'ef�.r.� ',�:�a Sein'-•.`k� ����riX r. ,i( ._i..,.:��Xy,,.,.•,'n��,," :+7.,.- U-'�,: "`^' it:� ''+ts�
�t �:"': �.(`rLryy-, :.,ir
Y�
-testi-•i.�`r'µ
` 1"" — :.r•
,1�
> a.
0,
;,DAVIE.,COUNTY HEALTH DEPARTMENT
arae:' f
-`;Environmental Health'S"on
PROPERTY INFORMATION
x��
' k� P.O. Box 848A
��. A
1A (111
Directions
IPe1tY -'
Mocksville, NC 27028'
Subdivision'Name:
L
ii�� �,lE•�� V fS, Z
Phone #: 336-751-8760
Un, j-�j{(��.it
Section:
r
AUTHORIZATION FOR : •,: ' iE`
WASTEWATER
Lot:
SYSTEM CONSTRUCTION
Tax Office PIN:# - -
AUTHORIZATION NO:
003-014 A
Road Name^ ��WS�'✓1
**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 HEALT SPECIALIST AT ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE /�# BEDROOMS # BATHS # 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 StZE eI %SNAL. PUMP TANKGr s -CfAL. TRENCH WIDTH _�RocK DEPTH 4W FT.ZrKy
OTHER I%I` 0 h rIA(b Ak
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
As stated in 15A
r
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
- SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"TILE 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.
- nctM aznx <Revi:eal, O�j ,1,/Vi1.7`r" %Z l b
r ertmfte� a41
pAVIE COUNTY HEALTH DEPARTMENT
Nattte."'c ��f VAI l� Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: ( Mocksville, NC 27028 Subdivision Name:
-mks In Jmo
Phone #: 336-751-8760
i Section: Lot:
AUTHORIZATION FOR
l'';! �, WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTION ��// �
AUTHORIZATION NO: 003014 A Road Name:': " 1 /19 , ,(A'aihLA n
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of tiny Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen -nits.
(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
i',ti IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH�PECIALIST bXTE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS _ S # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
i
LOT SIZE TYPE WATER SUPPLY 14 h DESIGN WASTEWATER FLOW (GPD) C� NEW SITE` REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE�'%�t � g,AL. PUMP TANK E k GAL. TRENCH WIDTH ROCK DEPTHLINEAR FT. �
OTHER Wyo (2 r t J o Yl r `�.
REQUIRED SITE MODIFICATION/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT,
t
•'/tet 1.
j
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
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 02/02 (Revised) M
O - :Zia W '17-10
G,;,A44ps GIS
BARR LN
9 -
Page I of 6
http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 2/23/2010
�• CAVIE COUN�EALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10,A 193�4,-.1968) Permit Number
Name /1'/'/_ ✓' 2'x%,/1 ! i,%�� �� 3 !E' �' "%//r� �FF"O bate � N2 i.� i��} S1 A
x,
Location !:���.1 rf^ .mac/-fr .' i�- 6✓' ��c % ,✓�i Frr m^.' ,! Y
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 fl NO fl, Specifications for System:
Auto Dish Washer YES r NO l] ���✓ � / "
Auto*Vash Machine YES lLJ NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
t
�a
//17fl -�a Y
15 y
Improvements permiNby � f LIQ
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30,-
9:30
:309:30 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,
Ft . i-"4�14� ��f'f".a-'�Y"r' ��-nr ; �+a•,v'�w�w.'+�".'-�C-"�'.1^"'^-_ .M1 �. '�A,�`�"'l.h'}.^'�':�.p;-;i+1til,K-�i�%L���:.��•.\-�,,;,wti:-''�-�
DAVIE. COUNTY HEALTH DEPARTMENT ,
,IMPROVEMENT AND OPERATION PERMITS. PROPERTY INFORMATION
e ttee's
IL 5 Subdivision 'Name:
Directions to property: t< :' ' i':•�t .Section: Lot: t f'
,IMPROVEMENT
i•-'" ' '' '�` �' d l� , I r� r PFRNIIT Tax Office PIN:#
.;r.a S
r Road N� e. $ . ► • n !-. p:
**NOTE**This Improvement Permit DOE&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
co truction/mstallation of a system or the issuance of a building permit.'
.(In complianc�dJ 'th- A thele -11` of G.S. Ch4pt6 l30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r ***NO'T'ICE*** Tfus PERNIIT LS SUBJECT TO REVOCATION IF SrIE
'PLANS OR THE INTENDED USE CHANGE. -YOUR WASTEWATER
ENVIRO`rNMFkT HE9 TH SPE Sfi' DA ISSUED 'SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM:
RESIDENTIAL SPECIFICATION: BUILDING TYPE BEDROOMS 3 't ` BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATIOM,,FAC, ITY TYPE#PEOPLE_ - # PEOPLE/SHIFT . #SEATS INDUSTRIAL WASTE: Yes or No
TYPE WATER SUPPLY�V� 7` r 'r Y" NEWiSTfE. REPAIR SITE
✓ ,
LOT SIZE I DESIGN WASTEWATER'FLOW
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL.. TRENCH WIDTH �1� ROCK DEPTH' I� LINEAR Fr. 70
` OTHER I 'J IJt F- A P,�O Tt o •J_ �jp Ali
REQUIRED SITE MODIFICATIONS/CONDITIONS: t4 St u . " u co NrOOL. ' im P d C NQ&b
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
r 13ETWEEN 8:30 -.9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHE7) 69969r
M' E �a� r•{ ' DAVIE COUNTY HEALTH DEPARTMENT r
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
'Permittee's + _
Name: r' z I Subdivision Name: i
Directions to property: Section: Lot:
r IMPROVEMENT
. 1 PERMrr Tax Office PIN:#
Road Name: ;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/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)
IS SUBJECT TO REVOCATION IF SIT`E
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
C� - Yr
RESIDENTIAL SPECIFICATION: BUILDING TYPE Q�i_# BEDROOMS F` 'r # BATHS -# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOTSIZE 1'%t,' TYPE WATER SUPPLY .L" L J� } DESIGN WASTEWATER FLOW (GPD) �! t> NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �' t' LINEAR FT. 70 ,
`tf' -.
� OTHER t t' t: � I`>Cy
REQUIRED SITE MODIFICATIONS/CONDITIONS: �: '� r�LL U � C_.J -A V `�" -O I �'
IMPROVEMENT PERIv� iA b - t' ' 1 - �. t=t{ .� F 1-11411:&IED taERD i
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 -X8960 -
a
OPERATION PERMIT
SYSTEM INSTALLED BY:
1.
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)
... _.. '.��'.—.t-.. _:•r+ -H` :,:. r.'eY .r .i:'- . . i. • [ :;— Y Itr{ eti '. .rev .Y. i t Ah t ff t I Y:
..AUTHORIZATION NO 4 5/ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848 r r
Name: LL11 Mocksville, NC 27028 Subdivision Name: �"'�UC -^(
Phone # 336-751-8760
Directions to property: j� E 70 �����Section: Lot:
AUTHORIZATION FOR
U 0,4 OlVt)69(� �,- 7c,- d WASTEWATER Tax Office PIN:# - -
SYSTEM T {. CONSTRUCTION
r L)v,.j Natel�sr� tL
CIA �r cs-El( J4 /`i L^A) (-"A(' �l;� C � ►• Lip � /GYM
i Road Name. kk,
**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 complianee ith Phi el of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
01 IS VALID FOR A PERIOD OF FIVE YEARS.
',Fj,1VI M TA # EACTH SPIECIA99f DATU ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
Environmental. Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
T(Check One) E$LACEME T ❑ REMODELING ❑ RECONNECTION ❑
Name: � �`� �� Number: i J�y 1 `� Home( )
Mailing Address: � /L/r Poe
i (� ` J �� t (Work)
Lvl
Detailed Directions To Site:
r
Property
Please Fill In The Following Information About The Existing Dwelr14. ,1
Name System Installed Under: CrjA rJ A L • N Type 'Of )Dwelling:
Date System Installed(Month/Day/Year): Number Of Bedrooms: ' L`'o-% Number Of People:
Is The Dwelling Currently Vacant? Yes No ❑ If Yes, For How Long?
Any Known Problems? Yes ❑ No ❑ If Yes, Explain:
TOYbL 0-4 ' y 6bp�OM)
Please Fill In The Following Information About The New Dwelling-
Type Of Dwelling: h W TqkNumber Of Bedrooms: Number (ffeople:
Requested By: s /�'''' Date Requested: C U
(Sign lure)
/ "
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments: SS0 z 0 1&-, I luv eh., a.\ f 1.. Z 1' 0 iii, A LLO L3
i/
Environmental Health Specialist f � Date
'Me 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 function properly for any given period of time.
Payment: Cash ❑ Check ''Money Order ❑ # "1 Amount: $ Date: 7— t7}
Paid By: Received By*�nn
Account #:- 9 Invoice #: C7 J b
' ' :�90
/ ~ �
� ~ ' ���� ������ HEALTH DEPARTMENT-
' , ^
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued inCompliance with G.S.of North Carolina Chapter 130 Article 13o
Sewage Treatment and Disposal Rules (10N UA
Namo
Location
Subdivision Name
Permit Number
N��
n��
— Sec. or Block No
Lot Size House Mobile Home -_-__---_Business --_--_--_Speculation
No. Bedrooms - No. Baths ' No. in Family
------___-
Garbage Disposal YES [] NO B Specifications for System:
Auto Dish Washer YES 0 NO C]
Auto Wash Machine YES [D NO {]
Type VVo1er Supply
*This permit Void if sewage system described
be|
\�
i i
months
from dobe of issue.
/-
��7|' /�'��^�
�^' - . -~'��//
Improvements permit by 71—'� ZZ
°Contaota representative of the Davie County Health Department for final inspection of this oyeham between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 7O4'634'5S85.
Final Installation Diagram: System Installed by 5—�ayx-,
Certificate of Completion Ombe
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth inthe above regulation, but shall inNO way betaken oaaguarantee that the system will function
satisfactorily for any given period of time.
's �`' � . ` i � a-y1/� r•Z� � C• �, � � f/t L�yl�— 76 y � > D � G�GL7 f
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAMEiis-4 Z04::� !i` PHONE NUMBER
ADDRESS Q SI /� SUBDIVISION NAME
e_ LOT #
DIRECTIONS TO SITE / JU I �d.i,n� �C� �/O G�t�r �e>e
ccDDt,p 1-
DATE SYSTEM INSTALLED i �I E SYSTEMaYINSTALLED UNVE� A.`L! V-4" a &A j 39) 7
TYPE FACILITY �57 NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �C) SPECIFY PROBLEM OCCURRING S ew cam=►-�
St..tgc- C 4 ✓l ti -U
Ila � -2 P t e c N Q
DATE REQUESTEINFORMATION TAKEN BY_ S
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. 103
f INFORMATION FOR.SEPTIC SYSTEM REPAIR PERMIT
NAME •J. �j(l' � %j �j` l� �� PHONE NUMBER 'rf-
ADDRESS _ - ,�Qx/�b i SUBDIVISION NAME
SUBDIVISION LOT #
DATE SEPTIC SYSTEM INSTALLED
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
/ i I i
0
SPECIFY PROBLEMS THAT ARE OCCURRING lVaozL=.E
6�lw7�'L -,:�* '(2ar -z-1 -,7L- u Ja--.5� �- 0- /&/� e �.
DATE REQUESTED -� INFORMATION TAKEN BY
04< DAVIE COUNTY HEALTH DEPARTMENT
7 -
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date 531
No
Location
Subdivision Name
Lot No. Sr~r — Sec. or Block No.
Lot Size House 4<-- Mobile Home Business -- Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ;E] NO C] Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Machine YES ED NO C]
Type Water Supply S
*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 1 2S!Z�j
C -
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.
. ......... .. .
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 1 2S!Z�j
C -
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.
T
INFORMATION FOR.SEPTIC SYSTEM REPAIR PERMIT
NAME1� �%�� �f ��%Cl PHONE NUMBER'
ADDRESS- ,6�Q J�-ii SUBDIVISION NAME
Tie—
� SUBDIVISION LOT #
DIRECTIONS TO SITE � -
A-57 4 -
Ad— ehol a e* �4? e -
DATE SEPTIC SYSTEM INSTALLED /, ` 1-E / -� .
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPECIFY PROBLEMS THAT ARE OCCURRING CtC ~
d,,)&JkSIS-1a�S
DATE REQUESTED /-- INFORMATION TAKEN BY
P
DAVIE COUNTY HEALTH DEPARTMENT
y (Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR DATE PERMIT
LOCATION,; f'� r
z, t.,..
,N?
1468
S.R.
NO.
SUBDIVISION NAME ". j E tt,"� , �,, ¢> ,.
LOT
NO. «„ s SECTION OR
BLOCK NO.
HOUSE El MOBILE HOME
BUSINESS ❑
House Trailer
800
Gal. 400
Sq.
Ft.
N0. BEDROOMS N0. BATHROOMS �'�.
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 ❑
NO ❑
SITE SUITABLE YES ❑
NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
�
DEPTH OF STONE IN LINES:
v ux 42-11
WATER SUPPLY: Individual
Public ❑
IMPROVEMENTS PERMIT BY �',z.•:,:
INSTALLED BY Q.�--
CERTIFICATE OF COMPLETION By
(8/16/73) *Construction must comply with all
LOT AREA
Date
applicable State and local regulations
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Issued in Compliance -with G.S.'of North Carolina Chapter. 130 Article 13c
Sewage Treatment % a d Disposal Rules_ (10 NCAC 10 934-.1968) Permit Number
Name % N. NJD `f O
- 5394
Location 0Loll
Subdivision Name ��f,��'. Lot No. Sec. or Block No.
Lot SizeHousekf:f_ Mobile Home Business ' Speculation
No: ,Bedrooms _ No. Baths No. in -Family
Garbage Disposal ,..YES t]. NO "fl Specifications for System: .
Auto Dish Washer YES NO' i]
Auto Wash Machine YES NO' D
Type Water Supply.
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
)ran
F.
Improvements permit. by.
*Contact a representative of the Davie County Health Department for final inspection of this system between "8
9:30 A.M. or 1:00-1:30 P.M.,,,on,'day,of completion. Telephone Number:. 704-634-5985.
Final Installation'Diagram; i System Installed by _ '1 �i�.�ss��•
Certificate of Completion Date 1 O 1
"The signing of this certificate shall indicate that tFie 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 COUTY HEALTH DEPARTMENT
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A 1934-.1968) Permit Number
Name l/,� i� /' moi///� ,`;� t / �r' bate _--/.-� , NO t' .
Location /
Subdivision Name %�'�,�1"%%?r' Lot No. Sec. or Block No.
v
Lot Size House— Mobile Home _ Business Speculation
No. Bedrooms �' No. Baths No. in Family _
Garbage Disposal YES ❑ NO p Specifications for System: ,
Auto Dish Washer YESNO ❑_ { i! .- ,; -/�: < ,�?-?, '<
Auto Wash Machine YES p NO ❑ �" L
Type Water Supply __ �_�C ,rli/
'This permit Void if sewage system described below is not installed within 36 months from date of issue.'
rL7�9 �
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
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR DATE PERMIT
LOCATION N° 1468 �j � -1
S.R. NO.
SUBDIVISION NAME i.'1(` h,� �! LOT NO. i+ SECTION OR BLOCK NO.
HOUSE F�,] MOBILE HOME ❑ BUSINESS ❑
NO. BEDROOMS ' NO. BATHROOMS 0'h�
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD a D sq. ft.
DEPTH OF STONE IN LINES:
ciX-7y
WATER SUPPLY: Individual Public ❑
IMPROVEMENTS PERMIT BY , is
CERTIFICATE OF COMPLETION By
(8/16/73) *Construction must comply with all
LOT AREA
House Trailer 800 Gal.
Two Bedroom House 800 Gal.
Three Bedroom House 900 Gal.
Four Bedroom House 1000 Gal.
INSTALLED BY
400 Sq. Ft.
600 Sq. Ft.
900 Sq. Ft.
1200 Sq. Ft.
Date
applicable State and local regulations
J
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 f�,�Lo CN,��}ru�t"ui2(1 t)pLd C12e1 14� DATE ISSUED
ADDRESS a,;Z0 1L1rj , 6jg,,•.•- PERMIT NO.
w -S
Explanation of charge
A1,11OUNT DUE 41,5,," SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
Daiiie (gauntg Pealth Department
Unb Pnme Pealth '�kgenrg
P. O. BOX 665
CiHachsijille, North (tlnrolinn 27028
OFFICE OF THE DIRECTOR
November 3, 1986
Ms. Ann Baity
Kapp Associates
1328 Westgate Drive
Winston Salem, NC 27103
Re: Sewage Disposal System Check
Westridge Lot 451
Dear Ms. Baity:
As per your request, a representative from this office visited
the aforementioned site on October 30, 1986. The purpose of this
visit was to determine the condition of the sewage disposal system.
At the time of the visit, there was no evidence of any problems and
everything appeared to be functioning properly.
Please advise should this office be of further assistance.
Sincerely,
6&" 6 I7`4 Z' �/(. R
Robert B. Hall, Jr. R. S.
Environmental Health
skg
Enclosure
TELEPHONE
47041 634.5985
1.
allb Hume pealth ��geltcu
P. O. BOX 57
CMorI:obille,'Worth (atralina 27Q28
OFFICE OF THE DIRECTOR
October 18, 1976
Crowder Realty "
3528 Vestmill Road
Winston-Salem, N. C. 27103
Gentlemen:
Re: Lot 1, Section 1, Westridge: Davie County
This is to state that the septic system on this lot has been
properly installed and with proper treatment should give
satisfactory service.
Sincerely,
R. J. Duncan
Sanitarian
RJD:jww
Enclosures (2)
TELEPHONE
704/ 634-5985