1264 Eatons Church Rd1 4X
l ermittee's DAVIE COUNTY HEALTH DEPARTMEKT
r/kiirfie: ' L%- tAhcl 1jua - Environmental Health Section PROPERTY INFFORMATION S
P.O. Box 848 (,L J i
Directions to property: rj i0 Mocksville, NC 27028 Subdivision Name:
I„� r h Phone #: 336-751-8760
�. (7�.i . `=-'..� Section: Lot:
( k� { fC� - AUTHORIZATION FOR
to ..J 1;,. -J WASTEWATER
1 0 Tax Office PIN:# 5
SYSTEM CONSTRUCTION -
CITIt
AUTHORIZATION NO: A Road Name: ,t.l; E,;,tfjt Zi .
p:
"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,wi Artic I l -of 9 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.
ON E , AL SPEC ALIS DAT&SSiTED
'RESIDENTIAL SPECIFICATION: BUILDING TYPE } V # BEDROOMS # BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICnA�TION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
ga
LOT SIZEf, TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)" NEW SITE - REPAIR SITE_
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. ,TRENCH WIDTH11 ROCK DEPTH I LINEAR FT. I
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:.'A{}O' ll("'t ��W' • �.tr�GS
IMPROVEMENT PERMIT LAYO
**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 (336)751-8760.
•*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TWSYSTEM DESCRIBED ABOV&UAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 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 02/02 (Revised) /
.. DAVIE COUNTY HEALTH DEPARTMEN D'
Environmental Health Section r5 tip
PO Box 848/210 Hospital Street U
Mocksville, NC 27028 API?
Phone: (336)751-8760 , 5 2004
ON-SITE WASTEWATER CERTIFICATION FOR L rAL H�f�
(Check One) REPLACEMENT ❑ REMODELING ❑ RECON O1V
Name: �"/'�'1 /L y_—,�'/�1 % Phone Number: 33 61*'_' ffr ome)
Mailing Address2 �`/ %�/� S �' G sl Mork)
GLV, Z7Q Z 4
Detailed Directions To Site: /�7/
/g e"
Property Address:
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: rc m % \xi Type Of Dwelling: MR
Date System Installed(Month/Day/Year): 4 -- 2- - °► Number Of Bedrooms,--2=—Number Of People: Z --
Is The Dwelling Currently Vacant? Yes "o ❑ If Yes, For How Long?
Any Known Problems? Yes ❑ No G1/Ir_Y_es, Explain:
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling: '&OZIz-4!;eLNumber Of Bedrooms: Number Of People:
Requested By:-� U r� Date Requested:y �S
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑ _:!�
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By: Received By:
Account #: 1 �P Invoice #:� �—/
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street .
L. MoFksville, `NC27028
Phone: (336)751-8760
-
.. ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
' (Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION
Name: i %_��%f� 7/ N �i Phone Number: �3 /' �0 %d (Home)
Mailing Address: T �`/; /�N S �� c/ 33 G 'S/ 3SS� (Work)
271.2 d .
Detailed Directions To Site: �' eiT�,Q� s/ i'' �1✓ /- �J ?/ii"S G/� :�
Property Address: Q41, 4—
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed. Under: C rn ', 1 i i 7 r 6 i, c t Type Of Dwelling: rn N
Date System Installed(Month/Day/Year): G ;L - q %4 Number Of Bedrooms: Z Number Of People:
Is The Dwelling Currently Vacant? Yes &,-14o ❑ If Yes, For How Long?
Any Known Problems? Yes ❑ No p,/II Yes, Explain:
Please Fill In The Following Information About The Nem Dwelling.
Type Of Dwelling: G Number Of Bedro n1s:_, Number Of People:
Requested By: 0 ZI, Date Requested:
(Si a e)
For Environmm ental Hea Office Use Only
4 P%
Approved [I Disapproved ❑ J
—,
Comments: `--� Q ! K, , T �� -A►
_..
)I /lit/
_Environmental Health Specialist ~`" ` t Date p,
*The signing of this form by the Environmittal Healih Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewate{ system will function properly for any given period of time.
Payment: Cash ❑ Check ❑ Money Order ❑ #��_ Amount: $ Date:
Paid By: Recely?d By:
Account #: % (P ;° Invoice'#:
j9 t y 0
J'• r DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Sanitary Sewage Systems Rf��/ Permit Number
Name I '' �� Date �1- 3 �' N2 I 5 4
�j
Location ,,47
Subdivision Name Lot No. Sec. or Block No.
Lot Size / I've House Mobile Home _�'� Business —_ Industry
No. Bedrooms. .No. Baths —-`No. in Family_, Public Assembly Other
Garbage Disposal YES ❑ NO 0-" Specifications for System:
Auto Dish Washer YES ❑ NO 2-*'
Auto Wash Ma thine YES Z NO ❑ AV
�I a
Type Water Supplyamu'
*This permit Void if sewage system described bel w is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans ort 'tended use change.
Improvements permit by __4611—
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. ori day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by q�u
>:VCV9d'
r
{ g sires
Q
Certificate of Completion Date
'The signing of this certificate shall indjcate 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
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