182 Casa Bella Drive Lot 10.I,,— :. r *ti.--.r:-s,+ « r- - :`+r r.Y' Siatir. y,�*k `'t':)�'4li'G-.!" "f' -"Ttira rr A,re y�i'ta' ..�Fi•.t'l;..y. !`.Ya.-:..;%..s r,.�''.:75
<AUTHORIZATION NO:DAVIE COUNTY HEALTH DEPARTMENT JcP� �70
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Environmental Health Section /��y„pp PROPERTY INFORMATION.
Permittee ti u P.O. Box $48 O //,,��// ///// /%/
Name: n 7�� . ���� ��� Mocksville, NC 27028. Subdivision Name: 9 OOO� `a ` c
aat`itM�w�' Phone #• 336-751-8760 v�3
Directions to property: ��J !1 Section: Lot:
^� AUTHORIZATION FOR
r. 1 J F-D WASTEWATER Tax Office PIN:#
StSTFM CONSTRUCTION
Road 1Name: CASA Zip; Z-tx5l
**NOTE**. This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernlits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying p� r Building Permits.'
(In compliance with Article 11 of/G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
_- i
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
!, IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONM AL EALTH SPECIA 1�1 DIEIS UED
-.I1_1..a-111".,�i-x �'v... .R3 i.,:1 ..:,w r , -�.�._ - •: F _ -- � - _ -' I -1• t' i-
A•. DAVIE COUNTY HEALTH DEPARTMENT- , �' C F'� ; ..40
IMPROVEMENT AND OPERATION 4;00 PROPERTY INFORMATION,
Permltteers - `~ rE%OOd
Name:��t~ lA, Subdivision Name:
Directions to property: R'S ` wlt� l r1n v
Section:' Lot:
f IMPROVEMENT -
r PERMIT Tax Office PIN:#
{.✓'� v„J1!� `t„ +� 6- r. Road Name: �J- L h Zip: l i.{. X--
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constructionimstallation of a system or the issuance of a building permit.
(In compliance with,Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�r Ir/I;f•PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER `
SYSTEM CONTRACTOR MUST. SEE THIS PERMIT BEFORE
+ ENVIRONMENTAL`HEALTH SPECIALIST DAfE IStUED . INSTALLING THE SYSTEM.. ,.
RESIDENTIAL SPECIFICATION: BUILDING TYPE C�1t# BEDROOMS Z # BATHS # OCCUPANTS Z GARBAGE DISPOSAL. Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPL
YW DESIGN WASTEWATER FLOW (GPD)�Lo NEW SITEf{ 'REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH, ROCK DEPTH I2 LINEAR FT. (t
OTHER0'a r"a x l5'T, d4' )
REQUIRED SITE MODIFICATIONS/CONDITIONS:��
IMPROVEMENT PERMrrLAYOUT *APPROVED EFFLUENT FILTER* *RISER(S) IF 611 BELOW FINISHED .GRADE* -
�o'-,""'""� • N �.�•7 Ito' �� ' x � z ''
FI �sT'
to
"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 OFINSTALLATION. TELEPHONE # IS OAYMA x
(336)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY:
�r
I Z.
AUTHORIZATION NO. � ArOPERATION PERMIT' BY: DATE: )2-1 L
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS ESCRIBED LOVEOHAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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)
F. a' tip''*i�` a'. 7.+'� �1�' H t f 7 Y'i' t °fyi ^' •Y .'1 �.: ice... 1 : .
�•
- s 0 4, A . DAVIE COUNTY HEALTH DEPARTMENT
,r IMPROVEMENT AND OPERATION P Ij�1�IT#oo PROPERTY INFORMATION
Permittees
_ / fi
Name: " j�, i; 3. `? iy, � 1 lA t s Subdivision Name: {r`i Fes, �. �/,�
Directions to property: M t C' ,k�' �4 +� Section: Lot:
EUPROVEMENT
PERMIT Tax tOffice PIN:#
1 !�} i.` �_aVu..:"(/. )t, n+ LL,. c:n .. 1. Road Name:-, I Lgi zip:u
**NOTE** This Improvement Pem-dt DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
/"k -i 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 MH # BEDROOMS 'Z # BATHS Z # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
1 _
t LOT SIZE TYPE WATER SUPPLY,-t;l L DESIGN WASTEWATER FLOW (GPDy�—'t � NEW SITE REPEjIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `-'' ' ROCK DEPTH t Z / LINEAR FT. I t U
OTHER I�IS�i�.i�./Tlc7tJ 1�c7k C1� Noa� tx�ST�ay�
REQUIRED SITE MODIFICATIONS/CONDITIONS: *^ - 10
'IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTEO* *RISERtS) .IF vt BEL%J FINIStitD,GRADE*
' F`tii> N u".) L..1 1.
�
,a �� •�����- $ate., w.. `�,
r
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH9EPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 X.M. OR 1:00 - 1:30iP.M. ON THE DAY O INSTALLATION. TELEPHONE # IS 6611
1 , -(336 75 f -87613
OPERATION PERMIT
SYSTEM INSTALLED BY: �' W�T1r► c Oh TI
,
Cl?
S
M • � ons. v
,
1'
AUTHORIZATION11,�x((++•• A, NO. � OPERATION PERMIT BY: —C�DATE: 1 Z L
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS M 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
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
` l
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME
Gy�'y�� ��Q 0/s/a w PHONE NUMBERF �o
ADDRESS/)e lIQ 411yC-SUBDIVISION NAME 1�!/Cc116
SUBDIVISION LOT #
DIRECTIONS TO SITE w 15-r70- F-rf/f a,7 lee/ al�,,fCAwl
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k±/� cl
vea /fid Gas- LeI14
DATE SYSTEM INSTALLED :2GC oc.,iL
NAME SYSTEM INSTALLED UNDER -
SPECIFY PROBLEMS OCCURRING
t
DATE REQUESTED ��'�'�Y INFORMATION TAKEN BY�