106 W Robin Drive Lot 6.�ry;,.J '�'-r:; ii "`tl^" . <� rK ;:�r•..:.,:.w♦ y i :..7:•„ .y6 � .+r;i:�'.y r.. ...;f; .+Nt-.�.v.ry , � i, }:, _ .,,., .. ., .. _ W n ,+. ... .. � .. a
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AUTHORIZATION NO: `i 511 A DAVIE COUNTY HEALTH DEPARTMENT4OPERTY
/
Environmental Health Section INFORMATION
Permittees' P.O. Box 848 f
Name: F /e Mocksville, NC 27028 Subdivision Name:
' Phone # 336-751-8760
Directions to prop y: �a' r Section: 2 —Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
/ Road Name: �o�%h.�r• Zip: 2?-yoG
**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
1e,71 !
DAVIE COUNTY HEALTH DEPARTMENT'%�
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
:..Perinittee's � i� ��
�j f, r E_
Name:. ","�i^"���� f e �.r'Y/tt.+� Subdivision Name: /,�5 ,,�;r. - o
Directions to prop y: %, . r` Section: Lot:
IMPROVEMENT '
% PERMIT Tax Office PIN:#
***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 --7 # 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 7 DESIGN WASTEWATER FLOW (GPD) ' ��� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH/ROCK DEPTH LINEAR FT. /S '
1-9 A /) . / .1
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT "APPROVED £FFLU?I"C
(S) IE G" BELOU FIVISHED GRAD !->
**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 M37+3w
(336)751—a763
OPERATION PERMIT
SYSTEM �
INSTALLED BY: �1 „�-vim'— � 1TA ►L.c�L
t
l
I ,
3-�
a�
1Z.
..
AUTHORIZATION NO. 1� "A OPERA ON PERMIT BY: DATE: J /
**THE ISSUANCE OF THIS OPERATION PERMITSHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLE IN COMPLIANCE
WITH ARTICLE 1 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 05/96 (Revised)
q � i r ,1 ? -. °i. � 1 r`• -rte . m` � w,,'yj '4 •a:�p.. ,.- r Y` ry` t T:k_. ,
`16 1,�, DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS ROPERTY INFORMATION
;_Permittee's
Name: 6! Subdivision Name
Directions to property: ' - Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: n D r• Zip: Z 70 o 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
constructionhnstallation of a system or the issuance of a building permit.
an compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
SZyPLANS 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 f r' # BEDROOMS ��r' _ # 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 f .;3 DESIGN WASTEWATER FLOW (GPD) r NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH c LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT ttiPPROVED EFri.lIM4T i•'I4MILl- $IIISER(S) TF Ca" DE1OJ %1111SIIEG 6i?l111k:�;
{
**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 # ISIlti��
( ;131) 751-B7GO
OPERATION PERMIT
&�y
SYSTEM INSTALLED BY:'
AUTHORIZATION NO. 1�5 1' A OPERAbON PERMIT BY:-40&DATE: �9
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBE ABOVE HAS BEEN INSTALLE 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)
N
d
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
SUBDIVISION NAME
DIRECTIONS TO SITE I1,7_ -I& T 4POW�',
LOT # SG' "02 " (:"
3
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS - NUMBER PEOPLE SERVED
TYPE WATER SUPPLY / z, SPECIFY PROBLEM OCCURRING
DATE REQUESTED K// 7/ y'7 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 ry
Rev. 1/93 /�j(�fj� f 0 Q7Q
.a0 _S -b 76 0061�_'
0.,N 4,3 2 -