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442 Foster Dairy RdVerrriit e'S. {{ DAVIE COUNTY HEALTH DEPARTMENT Name: L ('• M- i 1 Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property:` r lyl 1 i" 1. ( 10 : I.� tj:? <J . AUTHORIZATION NO: 003003 A Mocksville, NC 27028 Phone #: 336-751-8760 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Subdivision Name: Section: Lot: Tax Office PIN:# RoaNam :+ (i `- % tin i 1 I/ 1-KlZip: **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) C� 1ATCISSUED ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '.lCl tct� t :_/t' (t `��I,..IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEAhTH SPECIALIST a RESIDENTIAL SPECIFICATION: BUILDING TYPE &, E # BEDROOMS �_ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE ^.3 rf- TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE i� REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �i ROCK DEPTH J/ LINEAR FT. REQUIRED SITE MODIFICATIONS/CONDITIONS: _�S p�O ) (, IMPROVEMENT PERMIT LAYOUT 4_'101 O -Qat FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT Y S, SEM INSTALLED BY: ska - 9 1 I AUTHORIZATION NO.._?'Do v OPERATION PERMIT BY: O"aDATE: dzaO "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES RIBED 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 WA$ BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) rd DAVIE COUNTY HEALTH DEPARTMENT Name: I ` Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property:0.1 Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER. Tax Office PIN:# - - SYSTEM CONSTRUCTION AUTHORIZATION NO: A Road Name: **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) . _ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ( !" c(tt.y, I f'4 t•' ,'J��'rj%� lC" IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEAI,"FH SPECIALIST DATE'ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE.. /Kr # BEDROOMS+ 1 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE 3-5 ti TYPE WATER SUPPLY J) DESIGN WASTEWATER FLOW (GPD) I rta NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE /000 GAL. PUMP TANK GAL. TRENCH WIDTH _S ii ROCK DEPTH,441.- LINEAR FT. ! OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: �� I F �� t 6 t.. � all ` 1 t'J( I L,_ IMPROVEMENT PERMIT LAYOUT ._._------- �. II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:304 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. II OPERATION PERMIT SYSTEM INSTALLED BY: LI Yl AUTHORIZATION NO. 0 O OPERATION PERMIT BY: /kau 2 22�v /aA DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES RIBED 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 02M (Revised) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ATC Number: 2672 AUTHORIZATION FOR WASTEWATER SYSTEM 'CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTTRRUCTIION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �G��(' Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall ii dic a he system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G a ter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken a a g ar tee that the system will function satisfactorily for any given period of time. U� r Q �0 - Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99 (Revised) Date: 16,�, Account #: 990001275 Tax PIN/EH #: 5840-09-6889 Billed To: Lewis Correll Subdivision Info: Reference Name: Lewis Correll Location/Address: Foster Dairy Road -27028 Proposed Facility: Residence Property Size: 33 acres ATC Number: 2672 AUTHORIZATION FOR WASTEWATER SYSTEM 'CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTTRRUCTIION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �G��(' Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall ii dic a he system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G a ter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken a a g ar tee that the system will function satisfactorily for any given period of time. U� r Q �0 - Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99 (Revised) Date: 16,�, Account #: 990001275 Billed To: Lewis Correll Reference Name: Lewis Correll Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5840-09-6889 Subdivision Info: Location/Address: Foster Dairy f-oad-27028 Property Size: 33 acres ATC Number: 2672 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction_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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type 171- #People #Bedrooms #Baths Dishwasher. Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing;, Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size AC Type Water Supply ��Pl/ Design Wastewater Flow (GPD) Site: New Er" Repair ❑ System Specifications: Tank Size/ ZJ GAL. Pump Tank GAL. Trench Width (�w Rock Depth /,2 Linear FrS60 Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative'ofthe Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Ls , Environmental Health Specialist's Signature: l Date: i ��"�✓ DCHD 05/99 (Revised) D� FE8 - 2 201 Xt vi �i ,.,. ''t �: `) :: • •; �1V1ROpVt�0US4T1 I dAll limp fipl e(Noop 'O'only Health Dcparlluent °?%11111' �iirnenW IIealth Scojon P.O. Bu.'L 8,18 110 Hoshilal ,SU-crl Councr ii : 09-40-06 .Mocksvillc, NC 27028 ON-SITE WASTEWATER CI;ItT[ AT1 N 1'()K DWELLING (Check tine) Replacement Remodeling Reconnection �v b4fr, 00;u)_ r i 5 beIKA� h ��- ?,qn dt In FAX: Gia(i) - 7.;,1- 1640 Name:.._ L�L�2t ,rrc. t _. ..•.�... Phone Vumhcr.�-3� �� l ' C e (Ilome) MailingAddre;s:_!7vCZ)*.Ler ; ��./. _j 3 tom, 7.5_ - `i.3 _(Work) 6,61 qo,3-qlqq Ihtuiled Ifircction, To Site:..�,<<c� H,��c�rl G rI ft. CJ,n� �.1 �� Q.1r•..1 v, r. f i�.1< i.�i r ifi,%g_ iJ^_uc�.,/ -/0 1/,/(ex.• Property Adtlrc�.:_ Please Fill In The Following Information About The RXISTING Facility: � hamtt System Installed Under: )_r_Nj A, Dale System Installed (Mundt.' )Me.,Ycar): � _e? _I`tunher l�f cdroonts:_ Number of People:— Is 71ie l;acility Currently Vacant? Yea t Vit Aay Known Problems? Yea lt`T'es, Explain:_,• ,_ __. .__ .. I�tl� iN �, ,- 3 Plestse Fill !n The FoHowing I nforntatiou About The ?VEil' f'aciiitv: C. 'type UfFocility: �a' 1�P' �uc��-� _ 51'L6 Cf' /?oOM S.1xi P i _ _� •• Numlrsol'Pco lc. __D.itu Requested:___ - tSignxturc) For F.nviroarnental FIC81111 Office Use Only Approved DisApproved (`rnnmt:nts: Fuirotimental Health SPeCialist__... _ _ _ __—Date:— *The signing of this form by the Environmental Hcalth Staff is in no way invaded, nor should be tatkccn as a guarantee — — (extendeZ.Cc�,_mqney '1 d') that the un -site vvatatcwater system will function properly for any given ptriud u1'ti-m^�c. Payment: rz Urdcr d _L. .t.0 l —,, : hail ]3y;_._ _. .�„ ._--- •• — �l.cccived ily: - ,�{� ACCOUtll i::.. � � - – —.. _... .— .–,Invoice y:_._. f+'4Z2 15 ZIZd 0$9tCSL9EE « ZZ:Et ZO•ZO-OIOZ