151 Hank Lesser Rd Permittee,\ DAVIE COUNTY HEALTH DEPARTMENT
J
i mg:i K' r /' Environmental Health Section PRO ERTY INFORMATION
Y_ / P.O. Box 848
Directions to property:
,NC 27028 Subdivision Name:
Phone#:336-751=8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
20,66
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 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
r y� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
'�
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE iL #BEllROOMS #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)- S NEW'SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH=^�-I - ROCK DEPTH t LINEAR FT.AS
} OTHER
4w;
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
CAS
1
**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 PERMIT
SYSTEM INSTALLED BY:
h
Y
; i
AUTHORIZATION NCYOPERATION 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)
j
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville,NC 27028 D
Phone: (336)751-8760
' JUL 3
ON-SITE WASTEWATER CERTIFICATION FO D LLING 2002
(Check One) REPLACEMENT❑ REMODELING ❑ RE ON
t' 1 DAV NNTH
Name: I vN�� �/ f I ,i Phone Number: &_ /7 ome)
!S �1
Mailing Address:
1 RAW '-)3s6' 7`-`-Y 791� (Work)
Detailed Directions To Site:-r///A/ Pt`,jX (0U 1 -S 6'h 9(/ Skene- Rd Qi►1 J q0 L
i0-1 cam. ry e4. 40 L 8v / vt hli-Al l :1-'.4 rd
k-4 cid a o eul d- s4cK ��;/.� e►I�// - , , /
Property Address: - 114,tlk I2tSe�
Please Fill In The Following+Information About The Existing Dwelling.
Name System Installed Under: Type Of Dwelling:
Date System Installed(Month/Day/Year): Number Of.Bedrooms: -Number Of People:
Is The Dwelling Currently Vac/ant? Yes❑ No 0�If Yes,For/How Long? /
Any Known Problems?YesJ�' No❑ If Yes,Explain:
Please Fill Fill In The Following Information About The New Dwelling.
Type Of Dwellmg-AiLzee Number Of Bedrooms:_._ Number Of People: --�
Requested By: X, z2z Date Requested: y J?
( ignature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments:
/—
Environmental Health Specialist Date
'"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: $ Date:
Paid By: Received By: �L
Account #: Invoice #: 7
1 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
PO Box 848/210 Hospital Street
r Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑
,.. �( ,
"Name: T WG Phone Number:--R-3�- (Home)
Mailing Address: S /7��K !.fi'S�h KC� ��'G- 7 `y7�j (Work)
-t// C. / ?
Detailed Directions To Site:1�L`� gig P4/ ID-b 1 rnr c/;U 1 .5 / 601 ig(A�S,une Pd per,J CIO L
1 12 1 'p ff 6"dII I�V , go l 1 V f xl
(
Property Address: &/ 1142h- h SSP!- lecicC�s'G'-��
i
Please Fill In The Following Information About The Existing Dwelling.
` e Led Fes-, ,.5�✓ , .
Name System Installed Under:��'I /L.. Type Of Dwelling: `
Date System Installed(Month/Day/Year): 4f-77 d Number Of Bedrooms:_ _Number Of People:
Is The Dwelling Currently Vacant? Yes❑ No 9"--ff Yes,For How Long? t
Any Known Problems?Yes,,B" No❑ If Yes,Explain:
Please Fill In'The Following Information About The New Dwelling:
Type Of DwellingNumber Of Bedrooms: Number Of People:
Requested By 2-zDate Requested:
0i attire
( , )
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments:
Environmental Health Specialist Date
*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 w4fuitction properly for any given period of time.
Payment: Cash❑ Check❑ Money Order❑ # Amount: $ Date:
Paid By: �". Received Bv: �
1
Account #: 75761Invoic #: