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193 Woodburn Place Lot 21P itee's DAVIE COUNTY HEALTH DEPARTMENT Name: /%� Y�/ /�� Environmental Health Section PROPERTY INFORMATION ��i P.O. Box 848 Directions to property: L/ /i!/D�/L-Mocksville, NC 27028 Subdivision Name:.i- /C/�/ Phone' #: 336- 60 AUTHORIZATIONION FOR Section: Lot: WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO: 002556 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 I I of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) IS VALID FOR A PERIOD OF FIVE YEARS. DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS jI— # BATHS ;* # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ # PEOPLFJSHIFTjj //��# SEATS INDUSTRIAL WASTE: Yes or No LOTSIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPDIJ�'NEW SITE l l REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAC. PUMP TANK' - GAL.` � TRENCH WIDTH ROCK DEPTHi11A LINEAR FI',/� REQUIRED SITE MODIFICATIONS/CONDITIONS: I IMPROVEMENT PERMIT LAYOUT )ml( lam' /��#t 6rys " f61181 f I/Lee-hri— I.� o/C/ WVkc 1 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30.9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. II OPERATION PERMIT AUTHORIZATION NO. OPERATION PERMIT BY: SYSTEM INSTALLED DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 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. ucBoovoz(ae.I:m)aC--c-;r I of (e e/ U <' n DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION J ,/ /}APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME_ ( /crlll r ,EJ.�/Ji �� PHONE NUMBER s " NAM LOT # DIRECTIONS TO DATE SYSTEM INSTALLED //2!�Z7/6NAME SYSTEM INSTALLED UNDER TYPE FACILITY_% NUMBER BEDROOMS `� NUMBER PEOPLE SERVED TYPE.WATER SUPPLY r SPECIFY PROBLEM OCCURRING P DATE.RE6UESTED INFORMATION TAKEN BY This its to certify that the Information provided is correct to the beat of my knowledge, and that I understand I am responsible for all chargee Incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rov.1193 Pe wee s i i + DAVIE COUNTY HEALTH DEPARTMENT N gie?'�t` %'1 •'4' i�/✓+" ErivironmentalHealth Section PROPERTY INFORMATION f� f7 P.O. Box 848 r^ tirecnons to pibperty: � Y..%' i-i'/.liLi/t / [,,,..Mocksville, NC 27028 Subdivision Name:J / Phone #: 336-751-8760 Section:—/ AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION I •`AUTHORIZATION NO: 0025556 A Road Name: Zip:+ 1, **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Sectionrior to, issuance of any Building Permits. This Fonn/Authorization Number should be presented to the Davie County Building Inspections l Once when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) „- �' !'�,%" �,r',(• / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION'" ,, IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED AA RESIDENTIAL. SPECIFICATION: BUILDING TYPE --,&— # BEDROOMS,_ # BATHS # OCCUPANTS GARBAGE DISPOSAL.Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE+SHIFT # SEATS INDUSTRIAL WASTEi, 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 LINEAR i OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: - u FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF PERMIT SYSTEM INSTALLED BY: I 1 TELEPHONE It IS (336) 751-8760. AUTHORIZATION NO. 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 GUAR4NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -- yL../ IxHororortR�;�a1 ... .... ....... - ..._...r: rr_7 "") � .i`. �? -1�'-'•:l::r'Li `. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name "r; _yid G,�r.?��ori> Date Location Subdivision Name �n r C" t 4-Y) rj-> I ILot No. 2 I Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply _ No. Baths No. in Family YES p NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ Specifications for System: ;2�f r? i fL /�) 0'; 3 X %v /I/ --,3 N [ *This permit Void if sewage system described below is not installed within 36 months from date of issue. t It.JyC' -_ b'.: i I ii 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 b6W4' . eelL Certificate of CompletioDate *The signing of this certificate shall indicate that the system descri ed�s 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 if Compliance with G.S. of North Carolina Chapter 130—Article 13c. ' I i Permit Number Name ': � poi 6A1Zwo07 Date Z — 0 — S r.,;, 0 A Location / 7-0 (AoD()drylz rt/ Subdivision Name ("/2` F 'e W --* -/--) Lot No. I Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: 12F?'el J /? Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES ❑ . NO fl Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. OL� � Cir ti \l�tL' r U� � U D AO > �tf FIrzST_ c,"I=ti_! 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 b,� "' WT2 r,>✓z Certificate of Completion�GL— Dates *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 betaken as a guarantee that the system will function satisfactorily for any given period of time. t' DAVIE COUNTY HEALTH DEPARTMENT /20 la0003v2r1 (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article.13C) OWNER OR CONTRACTOR �. ,r,'"i7 i� r• 1) (o • DATE .1 ' ` P ' 7' % PERMIT q c LOCATION �Dl ff7�,'t! ,r< �/ N?. 1006 J.R. WV. SUBDIVISION NAME (��r�tlta9C✓J f S�%f<S LOT NO. f SECTION OR BLOCK NO. HOUSE ©' MOBILE HOME BUSINESS ❑ House Trailer 800 Gal. 400 Sq. Ft. N0. BEDROOMS N0. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft. GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900,Sq. Ft. AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft. AUTO. WASH. MACHINE YES ❑ NO ❑ SITE SUITABLE YES ❑ 0 ❑ SIZE OF NITRIFICATION FIELD Al sq. sq. ft. DEPTH OF STONE IN LINES: 1</it' cfL w 1^3` P WATER SUPPLY: Individual�� ©� Public ❑ ,� '�j�7 IMPROVEMENTS PERMIT BY ti F 'I� jci •k ✓y INSTALLED BY D4'01 'k; /� CERTIFICATE OF .COMPLETION VBy �l/YLb�` Date S' (8/16/73) *Construction must compIfAith all other applicable State and local regulations LOT AREA St . y� \►: no t `�