542 Gladstone RdDAVIE COUNTY HEALTH DEPARTMENT f
Environmental Health Section
P. O. Boa 848/210 Hospital Street
• Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001415 Tax PIN/EH #: 9900 -EH -01415
Billed To: Belinda Hill Subdivision Info:
Reference Name: Location/Address: 542 Gladstone Road -27028
Proposed Facility: Residence Property Size: see map
**N*his Impro59ment/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 11 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 M - za 0 (AC; #People 1' #Bedrooms 3 #Baths
Dishwasher: C51 Garbage Disposal: ❑ Washing Machine: 2r/1, Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type,, #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply AU— Design Wastewater Flow (GPD) ,3&0 Site: New ❑ Repair
r/ Ii
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width '. Rock Depth Linear Ft. /Z
Other: LPj f 9-& AJTlo.,1 AX
Required Site Modifications/Conditions: kP 5D, �t.t- , la -P 16 XC r" t -"3a
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the 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.****
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Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
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Date:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001415 Tax PIN/EH #: 9900 -EH -01415.
Billed To: Belinda Hill Subdivision Info:
Reference Name: Location/Address: 542 Gladstone Road -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2595
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 nd Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA' STR I FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature e:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
Septic System Installed By:
Environmental Health Specialist's
DCHD 05/99 (Revised)
Date: I P!Vw %
130' Txi ,tet.
AU*I?ORIZATION NO: 17994 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION ~�
Permittee `:� P.O. Box 848
Name: Mocksville, NC 27028 Subdivision Name:
/ 7 G
Directions to property: Phone # 336-751-8760 ��y�-- Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
Road Name:/ -tA 57c- 6- -bZip:
**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 complian11 i ith Artjcle I 1 o�G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t D IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENPAL-HEALTH SPECkALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS
Permittee's—
Name: L..l,.
Directions to property:
} r IMPROVEMENT
,.,� _ f'1 t " c -�i dy ! ►> , 1! PERMIT
PROPERTY INFORMATION
Subdivision Name:
r
Section: 'Lot:
Tax Office PIN:# - -
r�/
;7 r
Road Name < . '. �,7„' 1 �.1 i? zip:
**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)
i
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
♦ �.,. _ - / �� PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVI NMENTAL: HEALTH SPECIALIST DA ISS ED SYSTEM CONTRACTOR MUST SEE TILS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE (A tL # BEDROOMS .-.3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TY�PE� # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY C DESIGN WASTEWATER FLOW (GPD)360 NEW SITE REPAIR SITE
22 // //
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH X3b ROCK DEPTH M' 11
LINEAR FT. 150- ,
OTHER , )STQ I �)OTt.-.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
A
am.,
�i114 ,Lzp 10, 6f -r
EFFLUEb1T FILTE-ftf *R EER (S) IF 6” DELA:! FIPliSHZD GFIADE*
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**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.
HH):XXX ltXX
%33-57 .1
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. 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 05/96 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AD OPERATION PERMITS PROPERTY INFORMATION
Fermitted's ..
Name: ('. i_ L 1 #1 1, ! 5
Directions to property:
IMPROVEMENT
".�?� PERMIT
Subdivision Name:
Section: - Lot:
Tax Office PIN:# - -
Road Name: { i ` Zip:
**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 ISSfJED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE IA t"1 # 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 x" I �► DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
1 'r I
SYSTEM SPECIFICATIONS: TANK SIZEt GAL. PUMP TANK- GAL. TRENCH WIDTH r� ROCK DEPTH ! er LINEAR FT.
OTHER 1 I 1%7 �.I r' t )T► J C%i� , �1 lr
REQUIRED SITE MODIFICATIONS/CONDITIONS
IMPROVEMENT PERMIT LAYOUT
111101. L"") -s
i":f'1:01J1=IJ EFi L111=t1S FILTER* iiaSi=r(s) IF 6" flrl 0•"R: t=IPdISr13 Gf:l?E
/1760 9;6.
•..� , �-� , i=ce +.,� o � � � � 4; ��' •J�
/UG,'I 1. Ikl�--•�►'�,� t � ..:. a �.7 �,'
iVJ
At ��, ri r'S ' 771_
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"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HE D ARTM fNF FOR NAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF I STALL TION. LEPHONE # IS (704) 634-8760.
x.,. + XYTali1f1:):H11
OPERATION PERMIT
AUTHORIZATION NO. OPERATION PERMIT BY:
v.. ter. 1-'-0' 16TH t_
DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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. rt:
DCHD 05/96 (Revised)
_ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street ES.R 0 2000
Mocksville, NC 27028
Phone: (336)751-8760 E1dV{RO,,{s!Eiarn� �t,t7u"
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: _�A. Phone Number: aQ (Home)
Mailing Address: pa(-'/ q d ` IM(Work)
Property
Please Fill In The Following Information About The Existing Dwelling:
�I i I %—(r✓ t c
Name System Installed Under: Type Of Dwelling: �
Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People:
Is The Dwelling Currently Vacant? Yeses❑ No 9-," If Yes, For How Long?
Any Known Problems? Yes ❑ No Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: T --'*)o` c b 1 eu ' �l'�' Number Of Bedrooms: Number Of People:
Requested 13 t Aj,— Date Requested: 1 aoc)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Environmental Health
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"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:
Paid By: 1 Received By:
Account #: Invoice #: l b
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital. Street
Mocksville, NC.27028
r Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: Phone Number:. (Home)
c� r)jQCJS s] -D __o U --, )(� Work
Mailing Address•_ �� � ^� " �g � � (�� —(Work)
D ed Directions To Site: le n Y —10 -,( Q
Property Address: L, i ' n o_ c%�Z;1; 4
Please Fill In The Following Information About
Name System Installed Under: {
Date System Installed(Month/Day/Year):
he Existing Dwelling:
Type Of Dwelling:
Number Of Bedrooms: ` a, Number Of People:
Is The Dwelling Currently Vacant? Yes ❑ P�J If Yes, For How Long? I
Any Known Problems? Yes ❑ ,-No IE f Yes, Ex lain: 1
Please Fill In The Following Information bout The New Dwelling:
Type Of Dwelling:
--T--)y` b e t' ' �'`' l4umbe Of Bedrooms: Number Of People: `
Requested By: �. =� t k �__ i� Date Requested: off. C
1'v< 1-ULV 11\
.ty
'Approved ❑ Disapproved ❑
Environmental Health
Health Office Use Only
,
j... �. ., -. c r. ,
;t i T)atP
The signing of this form by the Environmental Health Staff is in no intended,'nor should betaken as a , ; f
,,uarantee(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 #:_-_f Invoice #:
1
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