143 Feezor RdAUTHORI?A TION NO: 1458 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permitte.:' P.O. Box 848
Name: Mocksville, NC 27028 Subdivision Name:
Phone #: 704-634-8760
Directions to property: /e'ez rAJ Section: Lot:
fd AUTHORIZATION FOR
C�u WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
`l ZiSE d �'l Road Na e: )r:Le—Z--0l� Nip: Arlo-5?O
**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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
' ! ,rJ L Zi -
IS
r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,' �VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTHECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
'Permtttec—s,
0,057
Directions
Directions to property:�r'E'ZDr�c�
'tax,
Subdivision Name:
Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: --(a E Z- -4W Nip:AV-ff
**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
constructionrinstallation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
PLANSR THE INTENDED CHANGE. YOUR WASTEWATEIS SUBJECT TO REVOCATION IF R
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS Q # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY C !i DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ' ROCK DEPTH _ /0 LINEAR FT. c /;, /
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: ! ✓_���' - '/ j'�f
R
IMPROVEMENT PERMIT LAYOUT
0
f
"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 (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: !r. —
lax AVlelxl
VK-{
AUTHORIZATION NO. OPERATION PERMIT BY: z4z 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.
DCHD 05/96 (Revised)
k -V
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
"PermittEe's;r
Name:
Directions to property:
IMPROVEMENT
PERMIT
i
Subdivision Name:
Section:
Lot:
TaxOfficePIN:# - -
Ali ^ �7,
RoaY me: r�&-�z; t\`-2ip:
**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
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
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 # BEDROOMS ' # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE . # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY e"� DESIGN WASTEWATER FLOW (GPD), -9' `%t:! NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH .= ROCK DEPTH < LINEAR FT.�!f/% ,
REQUIRED SITE MODIFICATIONS/CONDITIONS:'
**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 (704) 634-8760.
OPERATION PERMIT {
SYSTEM INSTALLED BY: �-
10 -1
Qfva!
AUTHORIZATION NO. 1 OPERATION PERMIT BY: '4"/,/ 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.
DCHD 05/96 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORK,a HEET FOR SEPTIC SYSTEM REPAIR PERMIT
y
E NUMBER
ADDRESS_ SUBDIVISION NAME
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE R
SUBDIVISION LOT #
NFORMATION TAKEN BY