107 Brook Hill Court Lot 37'tT� Itis _ ,,,aw.rvr i ; e ."�rq."'� t,i�o''�• •` 1' ;` •-n. �,f
Ivy
r y 7 i•
DAVIDCOII�TTY HEALTH DEPARTMENT. �r
IMPROVEMENT AND OPER�IT>�ON PERMITS PROPERTY INFORMATION
,r,N _ eei"' - ;r�' ter. r � , . Subdivision Name.
Directions to' roe ° Section: Lot: u,
IMPROVEMENT
PERMIT Tax Ofiice'PIN:#
'w a Road Name Z'
**NOTE**'This Improvemepf'Permit•DOES NOT authoriiethe construction'or installation of'a septic tank system or any wastewater system: An
AUTHORIZATION FOR WASTEWATER SYST M CONSTRUCTION must*be obtainedfrom this Department prior to the '
construction/installation'of asystem or the issuance of a building pernut
(In compliance WIth,Anc�le l i W G.S'. Chapter 130A, Wastewa[er:Systems; Section 1900 Sewage Treatment and Disposal Systoms)
�! " .„' • v ell
M.` ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
ti PI,ANS'OR TIS INTENDED USE,CHANGE. YOUR�WASTEWATER
' =F SYSTEM CONTRACTOR MUST SEE THLS PERMIT BEFORE .
ENVIRONMENTAL HEALTH SPECIALIST . DATE ISSUED
STALLING�THESYSTEM.t
INf,,�t �' � a� .; a ,•, ,
RESIDENTIAL SPECIFICATION: BUILDING TYPE !y # BEDROOMS `� # BATHS # OCCUPANTS GARBAGE DISPOSAL. Yes or No .,
COMMERCIAL SPECIFICATION ,FACILITY TYPE # PEOPLE # PEOPLE SHIFT #SEATS INDUSTRIAL WASTE: Yes of No
z r, s.,
LOT `SIZE TYPE WATER SUPPLY O DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE r '"
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK •. GAL. TRENCH WIDTH, o P ROCK DEPTH � LINEAR FT /eU'
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
01
IMPROVEMENT PERMIT LAYOUT �l
OROS EFFIAJE) T Fl L # *RISER(S) IF 6' ,' BdL CW :FINI GRADE*
k
**CONTACT A REPRESENTATIVE OF THE DAVIE,COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF STEM
BETWEEN 8:30 - 9:30 A.M._OR 1:00 - 1:30 P.M: ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 63J 7 'KKK
I V7 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
,„Permittee's .
Name: Subdivision Name:
Directions to property: Section: Lot:
IMPROVEMENT
PERMIT 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)
***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 TILS PERMIT BEFORE
INSTALLING THE SYSTEM.
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
� l�
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH r ROCK DEPTHf LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*APPRO',Eli 0--FLUE:'NT FIL.TFRRISER(S) IF 61' BELOW FINIt"ZI) GRADE
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THI$ SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634X§9§ h XX x
OPERATION PERMIT j
SYSTEM INSTALLED BY: ./IG1�i/S�v'yr
,t
r
6PERAT10N
�/ AUTHORIZATION NO. PERMIT BY: I/^1Y 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)
NAME _(- , A
ADDR
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
DIRECTIONS TO SITE
PHONE NUMBER
SUBDIVISION NAME
LOT # "1J
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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. 1/93
t-
.. to<.. .. a y, �,-}'°x�i " "! 9 Zf ,9J:'�"`•, -art .. . -.3 r. ;'..§
AUTHORIZATION NO. ,j �' 3 9 DAVIE COUNTY HEALTH DEPARTMENT `
Environmental Health Section PROPERTY INFORMATION z
Permittees P.O. Box 848
Name: %r 7 Mocksville, NC 27028 Subdivision Name:
C74jJ t Phone # 336-751-8760
Directions to property: At7 � '- « /1 ; ( Section: Lot:
AUTHORIZATION FOR
6 WASTEWATER
`'r 4f�` t+ ✓ �~ SYSTEM CONSTRUCTION Tax Office PINK
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 com fiance with Article I 1 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 H SPECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
f W(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR ?� -E C, t 1 e : '- r • DATE a ` �r `7 PERMIT
LOCATION 7, ,> _ Q ,,, , ,, �, } 1�� N9 1013
S.R. NO.
SUBDIVISION NAME W oc��'Pe_. LOT NO. % SECTION OR BLOCK NO. .3
HOUSE ® MOBILE HOME ❑ BUSINESS ❑
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES (2- NO ❑
AUTO. WASH. MACHINE YES ❑- NO ❑
SITE SUITABLEc� YES E2' NO [3SIZE OF TANK ! � gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY . Yl \ ...• �.
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 S T' Co -
CERTIFICATE OF COMPLETION
By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
DAVIE COUNTY HEALTH DEPARTMENT
� (Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWPER OR CONTRACTOR }� DATE = PERMIT
LOCATION' ,a : ., N° 1013
S.R. NO.
SUBDIVISION NAME Worrjjr, LOT NO. % SECTION OR BLOCK NO.
HOUSE
BUSINESS L
n
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES ❑- NO ❑
AUTO. WASH. MACHINE YES ❑- NO ❑
SITE SUITABLE YES ADD- NO ❑
SIZE OF TANK ��'rta gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY{'> e 'ti
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
INSTALLED BY LC&
CERTIFICATE OF COMPLETION
By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA �,�J11JI&A
% y r b yvi"
G
4
G.