133 E Renee Drive Lot 25/A'",t�"rsntrT#�.r�r+.v.r.,-�;-:sw �..^i�"'=}i''�:;i"c:..:' v-,r'+y.n-•ij.va' ''%c•ncvM�.`"-v`;a�-•:.',-=-sir=-v'U�-n:r�''��Kv...��;-:;,.a-•.:..Y-„•.�•4:,,�h=* ws:n r-,:.)''",d.,-.xI � � ,.r--•�.s....s--T
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rnuttc's ”D VIE" COUNTY HEALTH DEPARTMENT
Name 9�l /' '� Environmental Health Section. " PROPERTY INFORMATION
��, it % s
4 P:O. Box 848
Directions to PmPeY t t^� +� Mocksville, NC 27028 Subdivision Name: :' '
ff ,�•' Phone #: 336-751-8760
, . Section: Lot: .2 s
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# -
AUTHORIZATION NOI 2294
94 A 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 compliance with Article; l l of G.S. Chapter 130A,"W8tewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r
'Al A. ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION'
f,� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE
RESIDENTIAL SPECIFICATION: BUILDING TYPE . # BEDROOMS «.3 #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 a. DESIGN WASTEWATER FLOW (GPD) .NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. .TRENCH WIDTH v ROCK DEPTH._ILINEAR FT. �� V
OTHERAA
REQUIRED SITE MODIFICATIONS/CONDITIONS:c
IMPROVEMENT PERMIT LAYOUT
d �J %� a
'i
IV
*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM 9:3
BETWEEN 8:30 - 0 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS :(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: i f X
1
tJ
' - .. •111 - ,
AUTHORIZATION NO:wri OPERATION PERMIT BY: "
DATE:
n.
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN I
HALL
IN COMPLIANCE
WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL BUTSSYSTEMS",LL IN NO WAY BETAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02002 (Revised) '
• � ,063
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME 'Rob4z- Ca'.e6tn PHONE NUMBER
ADDRESS 11`k 1-743'- 366.ti. ?C9 SUBDIVISION NAME U)94.W
Ink- L7 e alr
DIRECTIONS TO SITE 261 - T--^ to W WJL" - 1 C' C IAk J-- Aug+ - 2 rA kooh I, Or
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY I R NUMBER BEDROOMS 3 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. 1193
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Ji
*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
U,may®
Name — � %` rel '�YJI/ Date 3.467
Location
Subdivision Name. Lot No. ____2J Sec. or Block No.
Lot Size " House Mobile Home _ Business Speculation
No. Bedrooms �' No. Baths No. in Family —
i
Garbage Disposal + YES ❑ NO ❑ Specifications for System:
Auto Dish Washer j� YES. ❑ NO ,❑ /� ��� --
Auto Wash Machine YES NO ❑ �`
Type .Water Supply,
Q ---
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
l 0�
l• ft
6.
*Contact a represent
9:30 A.M. or 1:00-1
Final Installation
Improvements permit by
of the Davie County Health Department for final 'inspection of this system between 8:30 -
P.M. on day of completion. Telephone Number: 704-634-5985.
m:
System Installed by
i
it •
i
Ih -
'I Certificate of Completion — Date
*The signing of thisjicertificate 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
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 , t , ✓ �' Date s
Location
Subdivision Name Lot No. _ Sec. or Block No.01
Lot Size _
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
House
_ No. Baths --
YES ❑ NO ❑
YES ❑ NO ❑
YES 2NO❑
Mobile Home _ Business __ Speculation
No. in Family _
Specifications for System:
C` ,T Yom)
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
If
I
1
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 70,
' (Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposals,r System - G.S. Chapter 130=Article 13C)
OWNER OR CONTRACTOR r#11i t D k.i DATE PERMIT
LOCATION � � cl C/A -a, N?
48
S.R. NO.
SUBDIVISION NAME t�'llt�yc?"/r%ra LOT NO. .. SECTION OR BLOCK NO.
HOUSE MOBILE HOME ❑ BUSINESS
1
NO. BEDROOMS •., NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES ❑ NO ❑
AUTO. WASH. MACHINE YES NO ❑
SITE SUITABLE YES NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD .! 4;� 0 sq. ft.
DEPTH OF STONE IN LINES: Jr
WATER SUPPLY: Individual Public ❑
IMPROVEMENTS PERMIT BY i�"� �y, {~L::°='✓+....ci.
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom House al. J..Q0_..S.q. Ft.
Three Bedroom House 900_al.., 900,.5'q. Ft.
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
INSTALLED BY,s • /-�.�
CERTIFICATE OF COMPLETION By- '' ,•G�!-,���,,r Date
(8/16/73) *Construction must comp y wit all other applicable State and local regulations
LOT AREA
.� f_7
f i
0
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