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1351 Fork Bixby Rdttee s" J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848 PROPERTY INFORMATION erections to property: Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: AUTHORIZATION FOR t WSTEWATFR Lot: A Tax Office PIN:# - SYSTEM CONSTRUCTION AUTHORIZATION NO: 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 1 of G.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. ,,,,...ENVIROfJMENTALMEALTH SPECT GIST - DAT ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE (' 1 ii # BEDROOMS #BATHS 2-_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY `� IWTYDESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE pI SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: r IMPROVEMENT PERMIT LAYOUT 4 **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. OPERATION PERMITn , `� nn SYSTEM INSTALLED BY: , �1 l I V ` 1_ L- �-� No s►Tc. T l D0 3 t© or\ AUTHORIZATION NO. OPERATION PERMIT Y: PBEEN ATE: d "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT H ST DESCRIBED AB V STALLE IN C MPLIANCE 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 02/02 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 1 4 S& PO Box 848/210 Hospital Street � Mocksville, NC 27028 Phone: (336)751-8760 Ell ON-SITE WASTEWATEI ,CERTIFICATION FOR DWELLING (Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑ C Name: _D C00 l S L-AA)n) LA) 6- Phone Number: 33 � ✓� ! - � � 7 � (Home) Mailing Address: (3 ( EVIE OS f: 3 (Work) Wln01--sv" (((- M.0 - Detailed Directions To Site: Le q Cm5t- 4-0 F R /.' k L /A Z4 Ci sS - Property J Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: AAP, !n W � ( t : A iType Of Dwelling: M oW /.l F -/f) S6( IQ Date System Installed(Month/Day/Year): 1 Z- 5 (dP_4,?s Number Of Bedrooms: 3 Number Of People: Is The Dwelling Currently Vacant? Yes PJ No ❑ If Yes, For How Long? Any Known Problems? Yes ❑ No 6 If Yes, Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: tM O Lr L4 9 D t4t & Number Of Bedrooms: 3 Number Of People: 2, Requested By:. (Signature) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Environmental Health Requested: Q l2-4 le) z I *The signing of this form by the Environmental Health Staff is in no wLy4dtended, 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 #: _Z�/. C� Invoice #: �—% DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATE CERTIFICATION FOR DWELLING (Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑ Name: D 0001 ,�, 1_RtJt-) t A)6r _Phone Number: (Home) Mailing Address: ! < ` nF h�S I- I—A/JL.? (Work) wA1)r 1_ -so: 0 (1 M. ( . Detailed Directions To Site: LA.5 i 4.a F o 2 L ! x u, L ; A: R 17r 2f L."; l/ r� r �/t l I �� �'>I ��,' ✓l /� l� �� A ,�� "P Property , v Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: 114A R W (1:-A W ,-, Type Of Dwelling: Date System Installed(Month/Day/Year):/ 12-1S (,tyAP5 Number Of Bedrooms: 3) Number Of People: Is The Dwelling Currently Vacant? Y f'1es No ❑ If Yes, For How Long? < Any Known Problems? Yes ❑ Now If Yes, Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: IM A,'t & O NY & Number Of Bedrooms: J Number Of People: Requested By: (Signature) Requested: !2 -z/ _0 2 For Environmental Health Office Use Only Approved ❑ ((Disapproved El{{ C�nMMf.nfc. k'._...c-fA, C Environmental Health /G Z - I *The signing of this form by the Environmental Health' Staff `is in no wky-iritended, 4ior should be taken as a auarantee(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 1#y: / a Account #: I DAVIE COUNTY HEALTH DEPARTMENT ;, ✓� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name = �� (, ��) ,�1� 1� Date Location s �_ ,� 11 -, �,, _�,� �_�_. h1blO w c , _ Subdivision Name Lot No. Sec. or Block No. Lot Size fit !Z House Mobile Home _ ✓ Business —_ Speculation No. Bedrooms No. Baths No. in Family �— Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer YES ❑ NO Auto Wash Machine YES Q NO / 0 `l Type Water Supply ;<, y t til *This permit Void if sewage system described below is not installed within 36 months from date of issue. ti� V'N 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. Tele -phony Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion ��'<< � Date Y� ' 2 *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. i DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME 0�,/1 r S r'l 1 �� PHONE NUMBER -,� ADDRESS SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93