3297 Hwy 158 (2)DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 /
IMPROVEMENT/OPERATION PERMIT
Account #: 989900216 t�`� Tax PIN/EH M 5850-38-9268
Billed To: Paul Willard w"�'� Subdivision Info:
Reference Name: Charles Hendrix Location/Address: Highway 158-27028
Proposed Facility: Residence Property Size: .657 Acres
ATC Number: 2863
**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 #People #Bedrooms 3 #Baths 2
Dishwasher: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: d
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 04961 QCT Type Water Supply C45�-r1w Design Wastewater Flow (GPD) 3(,p Site: New GI/ Repair ❑
System Specifications: Tank Size tCCOGAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft. oc�
Other: s?o 2.�tx rta a 5�'ST�n� i F?4`f N11� -T5 N '� &C els : IgA
Required Site Modifications/Conditions: l g t_ O►.{ cx> T3 l voz:p OFF
IMPROVEMEN770PERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF « 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 1:30p.mth
. on e day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signature• Date: 1 4/0
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CHD 05/99 (Revised)
77--^7--uuu almensions, structures, setbacks, and septic locations).
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No.
Invoice No.