1854 Cornatzer Rd " '1r17""..:i+f`T' "^.�'±:T 7 'i' r4•..•. ^7 ti•..,�`. 6}.,..ia v/�.+.Y'h�.iS "Y 9`K"' "i«a...;'� r�)v-' .'uf-,f+'f�i aar:7.
`AUTHVRIZATIOlNO �i % ' / DAVIE COUNTY HEALTH DEPARTMENT G
. , .
Environmental Health Section •PROPERTY FORMATION
_Permittee's `" P.O. Box 848
_._Name: t'`�4NL_0 CIM1"T1-� • ';' Mocksville,NC 27028. Subdivision Name:
b t ; Phone#`336-751-8760,
Directions to property; C_ 'I" Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
14Cc
U
Road Name. :r�Cr.3L\1�uTL zip �t1Z. ,
**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 applyin or Building Permits.
(In compliance wig,Article I I G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
`✓f '" ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR PERIOD OF FIVE YEARS.';,
VIRI3TH SP IAOST,' D T ISSUED .
yo•"a�:.a•.." e.M,
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r ,� �4 I DAVIE COUNTY HEALTH DEPARTMENT i
` T = IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION >'
.•y Pe3�mrttee's �, , ' , ! ,.,�
Subdivision Name:
Directions to property: G "I v
.- Section: Lot:
£ ` IMPROVEMENT
r` m E •�J PERMIT
_••�- Tax Office PIN:#
!
Road Name. 1Zip:2 f y
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An 'y
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 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems),'.
r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
x f^• 1id INTENDEDPLANS OR THE K TER
SYS M CONTRACTORMUST SE E THIS YOUR
BEFORE
.'ENVIRONMEN "ALTTEALTH SPECIALIST DA ISSUED
r . INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS m.� #BATHS _#OCCUPANTS�GARBAGE DISPOSAL Yes 'Nod
COMMERCIAL SPECIFICATION:, FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(6P1) L NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �Z LINEAR Fr.
OTHER 1 1
REQUIRED SITE MODIFICATIONS/CONDITIONS: �1'� JA or--1 ` Nj L7 1 naS'i A(�t r oOT L„t>-`,'1 "'V aC j,4 -t AI�,
IMPROVEMENT PERMIT LAYOUT ,
*APPROVED EFFLlJ.1 ILTER* *RIS E�t � F; " BEL13W FINISHED GRADE*'.
Nl ,�
•
**CONTACT A REPRESENTATIVE OF THE DAV OUNTY 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..
XXxXKHxxx
OPERATION PERMIT 5 �
SYSTEM INSTALLED BY:
)-� 00 SS
N G-2 T
AUTHORIZATION NO.I-j y i Q 0 RA N PERMIT BY 7: ATE: f 017—Jlp
**THE ISSUANCE OF,THIS OPERATION P IT SHALL INDICATE THAT THE SY TE VERIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCEWITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT DSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
�„���;,.�Ay,Et�'„y1��gpla.�.t,+��y,y�.��y�2�.::;�=tib aa`�,�-yy�;n;�'.:rr+�:4f•�i'no^�'„'�^.:+-:+M• h y.,ti"` .':''^.'> '• `jai r .�sx ' -... t - s'�:, 1 , req,,
Af
A _
174 DAVIE COUNTY HEALTH DEPARTMENT �' }
r,�.P�tmlttee
�. .
IMPROVEMENTAND OPERATION PERMITS PROPERTY`INFORMA
TION
N Subdivision Name: ti
�- -Directions to property: _ r 1. £ Section: Lot: d
IMPROVEMENT
►,�z;; 1 . . x i ; ? .� PERMIT Tax Office PIN:#
Road Name: Zip
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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***THUS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL:'HEALTH SPECIALIST DTE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE �Cx��` #BEDROOMS_H—#BATHS�2 #OCCUPANTS�'�GARBAGE DISPOSAL:Yes pc No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY y�:s DESIGN;WASTEWATER FLOW(GPD)-I=(4 Q NEW SITE REPAIR-SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH '�C ROCK DEPTH LINEAR FT:�,?
OTHER ' I , i'3 -
REQUIRED SITEMODIFICATIONS/CONDITIONS: 't1;I nrJ C-ml-J'1001raS;fn1..L r,k,"T 0,=:-T �',>w7 1.-5
IMPROVEMENT PERMIT LAYOUT
*APPROVED EFFLUT ILTER* *RI'SE14(9) t3 BELM) FIhI StMD CRADE.X•
**CONTACT A REPRESENTATIVE OF THE DAVI OUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
i BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
X3i)i}IxxxxH
-4a is
OPERATION PERMIT
SYSTEM INSTALLED BY:
j
• j,, j ���� ' �PP�R- Ll.•J61
0.1
AUTHORIZATION NOt�wl A O ERA N PERMIT B '/ f (l /,DATE: �� Z
**THE ISSUANCE OF THIS OPERATION P IT SHALL INDICATE THAT THE SY TE iLE RIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE'
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME,
DCHD 05/96(Revised) -
ti a ,
,,f
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
` APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 9!�
NAME ���/� ��� PHONE NUMBER ✓ /�'-���`S�
ADDRESS ��s`f �!�/��v�zG� �c�, _ SUBDIVISION NAME n
LOT #
DIRECTIONS TO SITE T/� .�`—� ��� o�/0 �� �1ac'1C_- a �v
ewd 614✓u 6n 7d
G Uelt 6
s6
7`0 Esc
DATE SYSTEM INSTALLE �� aJ NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ��`� SPECIFY PROBLEM OCCURRING
,,,40d?2�_
DATE REQUESTED INFORMATIONTAK BY
This is to certif�j that the information provided is correct to the best of my knowledge, th I understan respon ble for all chargps incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93