160 Casa Bella Drive Lot 13�' 7
Pennittee's'{� �. DAVIE COUNTY HEALTH DEPARTMENT
Name: • 1� Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: \� l.11 .M L�b 1C.", I Mocksville, NC 27028 Subdivision Name: OL -U,0 -",LL, (
id, 1�}[4�,F��}„L Phone#:336-751-8760
f Section:
AUTHORIZATION NO:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
002559 A
Lot:
13
Road Name: p• ��
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to I,, ce of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Off)ce/hep aoplying for-Baildingpermits.
(In compliancy lth ic; I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
i
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
D IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONME E"A'I;Tf,SPECIAt IS'T ATE I SUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE VA R # BEDROOMS 3 # BATHS # OCCUPANTS --;5 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY 1 DESIGN WASTEWATER FLOW (GPD) Z NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH d LINEAR FT. 2-Z�
OTHER 3 b/1STC1�Vrlo3 '�oX(S, �>r1t:Q,�dT1�Jt, VQL%/,
REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 ~L"1'� -j� OFC7 LJU,-C=• o FP PL, -p t--' '.
I IMPROVEMENT PERMIT LAYOUT
�_ _
0 - g01KC I
F IZ-R:r.rr
t14T. T
YAR%
1A.
FOR
S lYST�)n,.r
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.
OPERATION PERMIT
SYSTEM INSTALLED BY:
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
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. Q 10 O all
DCHD 02102 (Revised)
P�rnuttee s,, { �, DAVIE COUNTY HEALTH DEPARTMENT
Nams:: +-'+J '" Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 1
Directions to roperty:µ `r�i " tIAM i i-4. �'� Mocksville, NC 27028 Subdivision Name: �'' � I.%/At_I 4't
1. A', t �� +� �.:'!M ► h `,4 t1 Phone #: 336-751-8760 1
Section: Lot:
< AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - - — _—
AUTHORIZATION Nw, 002559
A Road Name: 1 ` (_ �'� ' f� "Zip:
**NOTE** This Authoriz
to issuance of
}` Offic'hen a
(In compliance:'w th Articl
• r
tion for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
ny Building Permits. This Form/Authorization Num"ould be presented to the Davie County'" -Building Inspections
plying for Building.J[ ermits.
.11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Sy's'tems)•
1 { r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION !
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENI'i L`H AL'TH SPECIA eIST TE ISSUED --�-•
RESIDENTIAL SPECIFICATION: BUILDING TYPE F I # BEDROOMS # BATHS- # OCCUPANTS GARBAGE DISPOSAL: Yes or No
1 � 1
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY {�'�'LN� DESIGN WASTEWATER FLOW (GPD) ('Q NEW SITE REPAIR SITE Ve
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH A LINEAR FT.
A e
OTHER t�I t tiT1�� �=+�5, ``4�L�n�Aft.Jt� �t0►.� VALVC
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
14 1
cC— tA0'
-4w j +f
� • tltw�C , .
ALT
V �T?
u_� -' b
VALVA
r'
ji "SYS�t�ti
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.
OPERATION PERMIT
SYSTEM INSTALLED BY:
01
_ AUTHORIZATION NO. --- — T OPERATION PERMIT BY: V 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. e5 .tt _4, 9 O q0 O D C/
nCHD 02102 (Revised)
'o IWY
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME C� PHONE NUMBER
ADDRESS �S SUBDIVISION NAME
LOT # 1 3
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED �a1tiS `� NAME SYSTEM INSTALLED UNDER��^rt'
/- -" 14 -
TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED 3
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING.—_�- —�'L--
DATE REQUESTEINFORMATION TAKEN BY-49—
This
Y!—This is to certify that the information provided is correct to ft best of my knowledge, and that I understand t am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
4+ .. '��f i.. ,l ,'ii,, :t� ,. �.,FrF /+j' .. o'aY �{, ry .eY�, a �Y i' ' `�+.�,1 .�".e .�,�•-YP�.-;l j.ef -sf .� `� '
DAVIE COUNTY HEALTH DEPARTMENT
• �l 1
IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION �'o b �,
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
2
Name o �� o�'C�"s Date `) 9 N2 �J 5
Location c�h : ")'t'N c N C 1 oy (1P
Subdivision Name �q Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths D_ No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer...YES ' ❑ NO ❑ t �.
Auto Wash Ma thine YES ❑ NO ❑ Y 3
Type Water Supply - C p_v u _y
_ *This permit Void if sewage system. described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
R
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:.
R
System Installed by
30
Certificate of Completion C� 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
IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION
*NOTE: Issued,in Compliance With Article II of G.S. Chapter 130a
• • '_ Sanitary Sewage Systems ...1 -^.
Permit Number `
NameDate, J J _ 1- N2
q685
Location �i ��t` y E. �� c �i�1 �- �1� U
%A
Subdivision Name \0 10 Lot No. Sec. or Block No.
Lot Size } vv y U o House Mobile Home — Business Speculation
No. Bedrooms No. Baths 2' No. in Family 3 _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ r t I
Auto Wash Ma shine YES ❑ NO ❑ �. �C �' f �,��
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
T This permit is subject to revocation if site plans or the intended use change.
�c
Lr a
i
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 Insflled by
1 t{
_ � G
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 rabove regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time. -