151 E Renee Drive Lot 23IO
~ A> TTH N NO: 0776 DAVIE COUNTY HEALTH DEPARTMENT A
Environmental Health Section PROPERTY INFORMATION
Permittee's} „� ,/ P.O. Box 848 /
Name: ,�'/1Jr T"�-?1r'%; Mocksville, NC 27028 Subdivision Name:
j Phone #: 704-634-8760
Directions to property: Section: Z Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# - -
/-.5,/ ,�.
Road Name: p . Zip: Z7,00
**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
a
DAME CtbUNTY HEALTH DEPARTMENT
"IMPROVEMENT AND OPERATION PERMITS PROPERTY ORMATION.
Parriiitee's,,� i3 U .
Subdivision Name: e:?�1144e ,�,
Duiechons to property: .� ,/ r ti j' /W Section: Lot: rte'
I� IMPROVEMENT
PERMIT Tax Office PIN:# _
ilei
ll ' `• RoadName:� Zi `TDD
p•,
**NOTE** This Improvement Permit DOES NOT authorize the congtruction or installation of aseptic tank system or any wastewater system. An,
AUTHORIZATION FOR WASTEWATER SYSTEMONS must be obtained from this Department prior to the
constructionfmstallation of a system or the issuance of a building permit
(In compliance with Article' 1 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
YSTEM:RESIDENTIAL SPECIFICATION'BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION:;, FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
n
LOT SIZE TYPE WATER SUPPLY,_ DESIGN WASTEWATER FLOW (GPD) i� NEW SITE _ REPAIR:Srm
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANKLINEAR FT.
GAL. TRENCH WIDTH L r ROCK DEPTH ! /
• OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT . ' ` a" a I
04,
)d
cvt 11
"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) 6348760.
u
OPERATION PERMIT 1.
SYSTEM INSTALLED BY:� ^
vSA",
'11 3
AUTHORIZATION NOTIU
. OPERATION PERMIT BY: DATE: _ 1
'd.
"THE ISSUANCE OF' OPERATION PERMIT SIiAI L 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 NOWAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION, SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
• 111
11
F
J•
DAVIE COUNTY HEALTH DEPARTMENT
~` IMPROVEMENT AND OPERATION PERMITS PROPERTY. INFORMATION
Name: r ,' .' r Subdivision Name:
Directions to property: �'� - Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road NamF'► i '? .Zip: ' /T O .
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.AAn
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 .? # BATHS #OCCUPANTS 5'— GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # 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 WIDTH ROCK DEPTH d `� LINEAR FT. /U
j
OTHER�4-
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
1
/y
� r
**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. '
i'
OPERATION PERMIT
SYSTEM INSTALLED BY: �•_ r. '� +�^± 7�
— t
U
AUTHORIZATION NO. L 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)
a. 4 �
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 i:, DATE'
PERMIT
el
NO
LOCATIONa�s"rt-,
SUBDIVISION NAME
S. R. NO.
LOT NO. 12 SECTION OR BLOCK NO.
63
HOUSE MOBILE
HOME
❑ BUSINESS ❑
House Trailer
800 Gal.
400 Sq.
Ft.
NO, BEDROOMS s
N0.
BATHROOMS CR
Two Bedroom House
8 Gal.
600,Sq.
Ft.
GARBAGE DISPOSAL UNIT
YES
❑ NO [
Three Bedroom House
900 Gal.
00�Sq.
Ft.
AUTO.'' DISHWASHER
YES
❑. NO
Four Bedroom House "
1000: Gal.
1200 'Sq.
Ft.
AUTO. WASH. MACHINE YES NO ❑
'SITE SUITABLE YES. b—"'NO ❑
._..SIZE- OF TANK gal.
. NITRIFI1CATION FIELD j O sq. _ft.
DEPTH OF STONE IN _ LINES s
WATER SUPPLY: Individual, Public ' ❑
s`• IMPROVEMENTS PERMIT BY * .:.a �,:.„. INSTALLED BY f / ',�•
CERTIFICATE OF COMPLETION � ��
BY Ad -
Date �"�--'
(8/16/73)..• *Constructi:on must comp .with all other applicable State and local regulations
LOT AREA
NAME W -4Z Pla
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION C� v
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
ADDRESS z4r( 'G" s- / P -e- r SUBDIVISION NAME A�ZQ�
�a'ylr, e e D0 6 LOT #
DIRECTIONS TO S
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 1 understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93