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,�:Li��HOqI�ATION NO: ��:� � DAVIE �OUNTY HEALTH DEPARTMENT 1
•., ��' ; Environmental Health Section PROPERTY INFORMATION
Perniitr�e's , � ° ,,,f' P.O. Box 848
Name R � ll�`� �.. /.-���✓` Mocksville, NC 27028 Subdivision Name:
r? �1 i Phone # 336-751-8760
Directions to property: �Gsf�r°/<' "'f ��/a, � Section: Lot:
� AUTHORIZATION FOR
�� �j�— �Q �S' �� � ��� WASTEWATER Tax Office PIN:#��y��%�' �'��
SYSTEM CONSTRUCTION
Road Name: .C7 �,� Zip: Da� 0
**NOT'E** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any BuildingPermits. This Form/Authorization Number:should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�
ENVIRONMENTAL HEALTH
/�j� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/�:J , %`./ s--qk� IS VALID FOR A PERIOD OF FIVE YEARS.
IALIST DATE ISSUED
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� r. �.';�.�`k+.: ` � °,� � �' DAVIE �OUNTY HEAf;�'H DE ARTMENT r
i �� �� TMPROVEMENT AND OPF,rRATION PERMITS PROPERTY INFORMATION :
,Permitf.�e�s �-� ,f ` %
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1Cjame�. .� ��{';;-�. t� r�:� �t Subdivision Name:
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Dir'ections+to property: c ;��i F< .�. }���.,}; �ii�.,-. : _
� " Section: Lot:
j r �, IlVIPROVEMENT
- ' � �f1 ,r; � /_� - r: f,;1 �` r PERMIT Tax Office PIN: r; •-'�c% _ �,`'�� _ `'!: �'c�..',�.
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Road Name. 1� 3'`_,�,9 �;� ^� /��Zip: � (� �
**NOTE** lfiis Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORiZATION FOR WASTEWATER SYSTEM CONSTRUCT'ION must be obtained from this Department prior to the
construction/'�nstallation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S: Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
� ***NOTICE*** THLS PERNIIT LS SUBJECT TO REVOCATION IF SITE
�!„�1� ''� � y ;-j�- 'y "� t PLANS OR THE INT'ENDED USE CHANGE. YOUR WASTEWATER
� * � � � � � �'�r��� � S� �� SYSTEM CONTRACTOR MUST SEE TEIIS PERMIT BEFORE
ENVIRONMENTAL HEALTH PECIALIST DATE ISSUED �STALLING TI� SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �� # BEDROOMS y�_ # BATHS �`�'^# OCCUPANTS y,L GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
r7�j �� �
LOT SIZE ��. //c� TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD) �� NEW SITE � REPAIR SITE �
.i ' �, .� /
SYSTEM SPECIFICATIONS: TANK SIZE �GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH � LINEAR FT. _��D
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
iMPROVEMENT PERMIT LAYOUT
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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 I:00 - 1:30 P.M. ON TNE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT �'�
SYSTEM I STALL D BY: 1 rJ �� �1�.t,.�.{L >
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AUTHORIZATION NO. �L� OPERATION PERMIT BY: DATE: �`7
*"Ti� ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO HAS BEEN INSTALLED IN COMPLIANCE
WTfH ARTICLE 11 OF G.S. CHAP'TER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPUSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII,L FUNC1'!ON SATISFAGTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
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�, b,_ , � � � �, � DAVIE I bUNTY HEAT;�'H DEP'ARTi:-�ENT .
- '� ,����-��`p IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
" '. i � � �
• Perm�Ct�e's ��-- ` ' -� ,` E ,
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.'l�jame. ¢� �.-+. tr.-:° t r�' Subdivision Name:
.
Directions to property: •• � Section: Lot:
... ,. i . � , '�:
IlNPROVEMENT
' PERMIT
Tax Office PIN: '#-'�� d-"�- ,_ - `"A��;�h'
r "'� 'S i + `�%
`t`F,' 1:;�1rf��',�`�Zip: �l: � �+
RoadName: �"- _..-.r.
**NOTE** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON must be obtained frc�m this Deparnnent 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*** THLS PERNIIT IS SUBJECT TO REVOCATION IF SITE
,�,`j`� ,j ,� , -'."` .: f:; PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH S�PECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TEQS PERMIT BEFORE
INSTALLING TI� SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS �_ # BATHS �# OCCUPANTS _� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
/, /7• � � � -�-�-r�
LOT SIZE � TYPE WATER SUPPLY /•' DESIGN WASTEWATER FLOW (GPD) � NEW SITE � REPAIR SITE �
, � .,. �/
SYSTEM SPECIFICATIONS: TANK SIZE C�i')d GAL. PUMP TANK GAL. TRENCH WIDTH .� ROCK DEPTH ��*� LINEAR Ff. ��G
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
,�' �,'� / -_
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�jrtA�1�&.'� �'r v..1 �
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•*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 930 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
6
SY TEM I STALL D BY: ��� ��
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AUTHORIZATION NO. \ 1[, l OPERATION PERMIT BY: � �� DATE: � ���
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**Tl� ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO 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 WII,L FUNGTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
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APPLICA710N FOR SIIE E�,�U1A110N/IMPROVEMENi PE!
Davie County Health Depardnent
'�: � Envfronmenta/Hea/lfi Se�cdon
P.O. Box 8�B/210 Hospital Street
Moaksville, NC �90�Q
(336) 751-8760
1 � �'�
**�II�ORTAHT*t* THI3 APPLICATIOTi CANXOT 8E PItOf�SSED ONLE38 ALL THE REQUIRED
INFORMATION IS PROVIDED. R�efer to the INSORMI,TION BOLLETIN for instruations.
a. Naam r,o be Htllea S} G• i� � S7�P '� contact rers�s �/,, %r �7`�'e /-�
xaslsnq Aearesa ��� 3�-� sama ghone %S"/— 3 3G /
City/Stiate/ZIP fi�U�..idr `/� /v ��70�� Business phone �%�� ^ 3 J� lv �
Z. llame on I�esmit/11SC ii Difleseat than
t
�) ci �
1lailing Address � "'.1��,�`�l � � � CiElt/State/2ip
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3. Applicatioa Sor: � � n ❑ Improv�oent Petmit/ATC � Both
�. syatem to senrsce: I�' House 0 Mobile Home 0 Busiuess 0 Iadustry 0 Other
s. If Residence: i People / � Bedrooms � i Bathrooms �/�-
fT�Dishxasher � Qarbaqe Diaposal �Nashinq llacbirse O Haae�ent/pinmbinQ 0 Hasement/No Plumbing
6. I� Bnsiness/Indnatsy/Other: 8peeity type
• Ca�odes
• shawers � Urinals
� peapie # Sinis
• itater Coolera
ITi FOODSERVICS: � Seats 8sti.mated iiater Osaqe �qailona per aay)
7. �►pe of Mater s�pply: f�' Conaty/City 0 i%11 ❑ Co�rmcunity
e. Do you anticipate Additioaa or e:pAnsiona of the facility t6is ayatem ia intended to aerve! 0 Yes � No
If yes, w6at type'
*"*IMPbRTANT"! CLIENTS JIlUST CO�ilPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Eit6er s PLAT or SITE PLAN �IIUST BESUB1btl?TED by t6e cUent with THIS APPLICATION. I
Property Dimenaionr. �i � 7� /��'�'�S WRITE DIRLCTIONS (trom Mocicsville) to PROPERTY:
� j
Tai Office PIN: # � � C10G��j �0,�',ivc�t_ � /,,%cz���u o.cJ �('�. �nrt�
Property Address: Road NAme ��d�'ijta�v �� (� 0/ .SQu 'f''�t
city/Zip �i16�s�','(� �t/� q7 �q'�
If in a Subdivision �rovide information, as followe:
Name:
Section: Block: Lot:
Date Property Flagged: �Q '� 0�/ d
This is to certify t6at t6e informAtion provided is correct to the best of my knowledga I uaderatand that any permit(a)
issued 6ereafter are aubject to su�pension or revocation, it t6e aite plana or iatended use c6ange, or if t6e information
submitted in t6is ApplicAtion ia falsified or c6aaged. l, also, understand that J am respo�rsiblejor all chwges incurred from
this appiicatio,r. I, dereby, give conaent to t6e Aat6orized Representative of t6e Dxvie Countx He Depa ent
to enter upon above described property located in Davie County and owned bc �TV.,I✓I l,t -�� �-('
to conduct All te.sting procedure� Aa necaaary to detecmine the aite auitabilih.
DATE �� �'� ��%� SIGNATURE_��!��Z� /f ��G���t�
THIS AREA MAY BL USED FOR DRAWING YOUR SITE PLAN (Include xll of t6e tollowin�: E�Jting and proposed
property linea and dimensiona, atrnctures, aetbxcks, and aeptic locations).
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Accouat No. o�'��
Reviaed DCHD (07/98) tnvoice Na � 10�
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