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143 Fork Bixby RdPerinittas .�---�� , � DAVIE COUNTY HEALTH DEPARTMENT oL//0 50 Nawmne =-,� � � r �i%�. Environmental Health Section PROPERTY INFORMATION • P.O. Box 848 Directions to property:`r % t , ? j Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: / ,•- AUTHORIZATION FOR WASTEWATER �! f✓�' r�, SYSTEM CONSTRUCTION Tax Office PIN:# - - 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 I 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. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED t RESIDENTIAL SPECIFICATION: BUILDING TYPE �p"�3 # 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 DESIGN WASTEWATER FLOW (GPD) f NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL/TRENCH WIDTH,--:? ROCK DEPTH , ! � LINEAR FTL",: % W) REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT g�Af-"5p� i I—Ieotl flu/, Id t **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPA TM NT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INST4LLI.TION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM AUTHORIZATION NO.r77�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. DCHD 02/02 (Revised) / / w� y. ,� . .. '7: y . ,. w —•;.,= 3a _...�� -. —. F z� ,_..—„.,.+..-,., t.. � ..-- �... ,., � ,...€.....-.. �_ ,.. �. ... ..., ..�... ,'--yam,.- .. • t7 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage System sPermit Number Name lP/� VA Date No 73„!. g7 Location a v%,,�.�1, ,�•�1� ��/vv✓so 7.� Subdivision Name Lot No. Sec. or Block No. Lot Size House t� 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 Ma thine YES ❑ NO ❑ �/ S /� 1, Type Water Supply __— N *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 int r(ded use change) r, y ImprovemIntl permit by —_ — *Contact a representative of the Davie County Health Department for ficial inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Teleph 6.nb, NuMber 704-634-5985. Final Installation Diagrams i /cam X3 x/D” t! T 1hst�lled by t� Certificate of Completion -- Date 119 "The signing of this/cetificate 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 willJunction 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,-, r ,r ?� 1 , __ Permi Number f _ 1q �! //' C� / . w �•i. Name / Date //r ��::A 1�` .Y`-L.l/r1J'(% t`•� L..- _//:.t v:•- -/jlf J� Location V /// I ' Subdivision Name Lot No. Sec. or Block No. Lot Size _ House t� Mobile Home — Business -- Speculation No. Bedrooms .No. Baths __ Garbage Disposal YES ❑ NO ❑ Auto Dish Washer YES ❑ NO ❑ Auto Wash Ma^hive YES ❑ NO ❑ Type Water Supply No. in Family — Specifications for System: *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 theirftended use change, 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 Diagranl:'Syst '�em Installed by — Certificate of Completion t `'t 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 CO UNY HEALTH DEPARTMENT IT 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 Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size 1 ` ` House l,. Mobile Home _ Business __ Speculation r.. No. Bedrooms No. Baths No. in Family _ Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑' NO ❑ Auto Wash Machine YES ❑ NO ❑ Type Water Supply "This permit Void if sewage system described below is not installed within 36 months from date of issue. 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. j v Final Installation Diagram: System Installed by \�s E Lloj-k r Certificate of Completion 01 Date )/ —.L '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. r 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. j v Final Installation Diagram: System Installed by \�s E Lloj-k r Certificate of Completion 01 Date )/ —.L '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 G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name Date Location I — Subdivision Name Lot No Sec. or Block No. Lot Size House Mobile Home — Business -- Speculation No. Bedrooms -- No. Baths — No. in Family—'-'..— Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑' NO 0 Auto Wash Machine YES p' NO ❑ ' Type Water Supply --- ` 'This permit Void if sewage system described below is not installed within 36 months from date of issue. 1-- . i ( i 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: System Installed by V ) Certificate of Completion �' -''��` r' ' 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. r INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT NAME .�%"1^-c_1�� PHONE NUMBER ADDRESSfSUBDIVISION NAME B0/0,60 SUBDIVISION LOT # DATE SEPTIC SYSTEM INSTALLED *" NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER SPECIFY PROBLEMS THAT ARE OCCURRING DATE REQUESTED ✓ �� T- r Cep\vvJ' D ATION FOR SITE EVALUATION/IhtPROVENIENT PERh11T & ATC Ov 2 2004 Davie County Health Department Environmental Health Section M P.O. Box 848/210 Hospital Street 01U�EA� Mocksville, NC 27028 RD'�f ppV1EG0 (336) 751-8760 I "—***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed .70SEPH W. 1 E,V/V /' Contact Person �i`..1Dr Mailing Address � nj� F�/lf� 0%��'1F. " 4y• Home Phone 7 ,Y 367! City/State/ZIP /`�`t��i'� -y/66 / V- (� ©� Business Phone 59 2- 70/6 3 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ,Improvement Permit/ATC ❑ Both 4. System to service: X House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: 110 Conventional El conventional modified ❑ innovative h 6. If Residence: # P✓e�ople 3 # Bedrooms 2 # Bathrooms .17 ODishwasher ❑Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) S. Type of water supply: X County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes A No If yes, what type? ***IMPORTANT''** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: �• �`�—�-' Tax Officc PIN: t) #1 7 -7 -7 y -7 Property Address: Road Name /` 2, City/zip lgpllAit e,— If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Name: Section: Block: Lot: Date home corners flagged: Z' X t S i- i �► �� u s 4-- 0 ,-, to co d Tliis is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I an: responsible for all charges incurred frons this application. I, Hereby, give consent to the Authorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. j DATE �� �/�` SIGNATURE liL TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 8 � Sign given Revised DCII t�c-,—"— r TO — Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. Invoice No. (5.79A) 4087 1271 (2.95A) 5849 1z71 (7.49A) 5740 12.79A 1523 (6.55A) 2574 1 w��"_ � l( ry zs1 �- ---• �(s FBF g 4--- 2 -(1 74co % p� "-4L1'T n6�'------ � -- 135 220 N I i--* 2 QA N N 299 3 07 116 (1.75A) 121 Qac 3398 (3.62A) 92451 83r---- 0 6234 ILi 2405 1 121 167-- ��'.--...... 9 (2.69A) ` N 0916 5 I w azo 8 (1.24 ° M 0746 ------------- 3 _ _ 86/10 + ss (2.37A) 05^ 1 w s �3� , o 35 (1.0fA), (9.72A) 3269 6249 2213 132tea (13.87A) 7935 (2.74A) s , 3052" 007111 ' V • ' Y 130 460 566 4863 9� 1616 /Qj 0676 n �j Vol (/ 6672 723 472 51 51 (6.84A) 9435 co (10.28A) 9726 �8- 165 O t V CID ' D a t , , (30o) 151 (136) r I I ' 281 v ; I I 282 M � 00 1.0 ' 1.386A 6887 * 2 CID141 + ( 1 A , 4 99 ' M 7 11 31, ' I , * °j 6 5 7 , i63 a +s 178 7A84 + , 1 0 , , M M r .40A) ; 4425, , O 27A) ,sa 40 95 (8.57A) 6197 33 NCGS'FORK 1948" o X=1.571,630.98 Y=778.165.12 (6.55A) 2574 1 w��"_ � l( ry zs1 �- ---• �(s FBF g 4--- 2 -(1 74co % p� "-4L1'T n6�'------ � -- 135 220 N I i--* 2 QA N N 299 3 07 116 (1.75A) 121 Qac 3398 (3.62A) 92451 83r---- 0 6234 ILi 2405 1 121 167-- ��'.--...... 9 (2.69A) ` N 0916 5 I w azo 8 (1.24 ° M 0746 ------------- 3 _ _ 86/10 + ss (2.37A) 05^ 1 w s �3� , o 35 (1.0fA), (9.72A) 3269 6249 2213 132tea (13.87A) 7935 (2.74A) s , 3052" 007111 ' V • ' Y 130 460 566 4863 9� 1616 /Qj 0676 n �j Vol (/ 6672 723 472 51 51 (6.84A) 9435 co (10.28A) 9726 �8- 165