119 W Renee Drive Lot 7-9At1 I ,-d'RIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848
Name: "',� �� �1����� Mocksville, NC 27028 Subdivision Name:��
{' Phone # 336-751-8760
' Directions to property: U 1 '.n o 0uu' ('" C C Section: ~� Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
� SYSTEM CONSTRUCTION ?
ST 0 --1 L Road Name: W � N � ! Zi r
**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 compli4nce with,Anicle 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
- ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�, ;. - . U✓%
IS VALID FOR A PERIOD OF FIVE YEARS.
-ENVIR NNtENJ-ArfA
HALT SPE LIST D TE 1 SUED
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I)AVIk. COUNTYBEALTH DEPARTMENT'
-;,IMPROVEMENT AND'OPERATION PERMITS PROPERTY INFORMATION
i.- ermittee s,
Subdivision Name: L
S e'cti n.
i6 propert ;J - , ---4> ' - - Lot:�
ons z o
E%VROVEMkNf.
I'N 'PERMIT_?-. Ti 'Office PIN:#
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Road, ame: ip:
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NOTE** T Improvement Permit DOES NOT audiorize the construction o' installatio'n of a septic tank system or any wastewater
r system. An
-AUTHORIZATION. FOR WASTEWATER'SYSTEM C0NStRUqn,.,0N musi be obtained fibin this Department to the
P149r
constructlohrinstaliatibn of a system or the issuance of k building perihii'
(In compliafic� with Article 11, of G.S.'Chavier 130A. Wastewater Systems, Section'. 1900 Sei�age Treatment and Disposal. Systeni)
REvocAnm IF SITE
'PLANS OR THEINTENDED USE CHANGE. YOUR WASTEWATEW
u.,
�**NOTICE*** THIS PERMIT IS SUBJECT TO
_'TM9AL1f SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEF.QRE..'�
IR6*&4t�A -H TSPtCfA ISt b TE fSS1 JED
:INSTALLING;TffE:$YSTEM.:
:.�RESIDE!SM, �.SPECIFICATION: BUILDING TYPE #BEDROOMS # BATHS. 0'
CCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATTON:,FACILITY TYPE # PEOPLE - # PEOPLE/SHIF� #SEATS INDUSTRLALWASTE: Yes or No
.wtsin?h� MWEME WATER SUPPLY DESIGN WASTEWATER -FLOW (GPD) '3(a NEW SITE REPAIR SITE
SYSTEM'4E'C1FICA'n`O_NS: TANK SIZE -GAL . PUMPTAN . K ROCK DEPTH LIN"EAR
----.GAL. JRENCH WIDTH I
T- 103 —?So)(
OTHER6
REQUIRED SITE MODIFICATIONS/CONDITIONS: lobrw_
IMPR&EMENT PER'WT
'Pit ED EFFLOENT FIL*R* *RISEO(S) IF 6119 BELOW FINISHED 61�4
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"CONTACT A REPRESENTATIVE OF
THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL
INSPECTION OF THIS SYSTEM
ETWEEN `3
B 86 0.- 9:30 A.M. OR
1:00 - 1:30 P.M. ON THE DAY OF 'INSTALLXTION. TELEPHONE # IS (OfMWN
P30751 -876O.'".
-veo
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME cS4e-j e— PHONE NUMBER
ADDRESS l l 1 W -Renee D k• SUBDIVISION NAME (-A.J O o cC � e f.
) s /J C --,?- 7 a 0,6 LOT #
DIRECTIONS TO SITE l9 �^ �"O e -w 1 a k t R p(_ 4 -CA -'e -"V ( �-_) � 9
el., x,671" -rkaA,3
DATE SYSTEM INSTALLED S NAME SYSTEM INSTALLED UNDER GVW"
TYPE FACILITY HnKA.- NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY
__�Q�' SPECIFY PROBLEM OCCURRING � e- f" a'4- d rr. �N
�r r' e s o (1 C=g �k_ �, ON 0 �- .� S y Soh- 64GKi�(2 0P
DATE REQUESTED � 1 5'-° 2— INFORMATION TAKEN BY D -f' �v�►PI�1 � ����
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
' J
J DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Dis o System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR P, 4t DATE $r 14 • IJ—PERMIT
LOCATION Al. 0 N?
S.R. NO.
SUBDIVISION NAME �pp Q l e LOT NO. SECTION OR BLOCK NO.
HOUSE [jam MOBILE HOME U BUSINESS !
NO. BEDROOMS _ NO. BATHROOMS /
GARBAGE DISPOSAL UNIT YES E3' NO R
AUTO. DISHWASHER YES ENO [IAUTO. WASH. MACHINE YES NO ❑
SITE SUITABLE YES NO ❑
SIZE OF TANK gal. tit.
NITRIFICATION FIELD • ,r42 sq. ft.
DEPTH OF STONE IN LINES: SIV.
WATER SUPPLY: Individual ❑ Public ❑
IMPROVEMENTS PERMIT BY L4" s
House Trailer
Two Bedroom House
Three Bedroom House
Four Bedroom House
It
614
800
Gal.
400
Sq.
Ft.
800
Gal.
600
Sq.
Ft.
900
Gal.
900
Sq.
Ft.
1000
Gal.
1200
Sq.
Ft.
r
?®o -! I i ua /&Tf "
r
INSTALLED BY to eC
CERTIFICATE OF COMPLETION-
Bv Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Dis osal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR QCal
DATE %d+ • 7PERMIT
LOCATIONtlt , f �'" �' NU 614
S.R. NO.
SUBDIVISION NAME OD d j,� , LOT NO. SECTION OR BLOCK NO.
HOUSE Q51- MOBILE HOME ❑ BUSINESS
NO. BEDROOMS _ NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO 520
AUTO. DISHWASHER YES :�'NO
❑ NO ❑
AUTO. WASH. MACHINE YES NO ❑
SITE SUITABLE YES ❑
SIZE OF TANK ea
gal. t/,..,-
NITRIFICATION FIELDsq. ft.
DEPTH OF STONE IN LINES: Iti.
WATER SUPPLY: Individua/l�2 Public [3IMPROVEMENTS PERMIT BY C.,-'I�G�I.C'G. /G•.4�
CERTIFICATE OF COMPLETION By
(8/16/73) *Construction must c
LOT AREA
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.
r
9&Vo -*q.� f+ F. tj ; tO IVA7 f
INSTALLED BY D� C
�' / ` � cif✓✓..1��✓(�- � _ � � - � �J
Date
with all other applicable State and local regulations
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