216 Gladstone Rd -
1F .
At1THORIZATION No:
0976 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee'-9--'-),, P.O.���'�:S U tJ P.O.Box 848
Name: � Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property: �U Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION `
' c c cs Road Name:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of anyBuilding Permits.This Forin/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED A..
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permitf6i--s 3
Name: Subdivision Name:
Directions to property: Section: Lot: f
IMPROVEMENT
PERMIT Tax Office PIN:# _
x Road Name: k;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)
f M� ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�• �.: `. PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER -
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
r GARBAGE
.'RESIDENTIAL SPECIFICATION:BUILDING TYPE'; >�.#BEDROOMS #BATHS �., #OCCUPANTS DISPOSAL:Yes opr(&
COMMERCIAL SPECIFICATION: FACILITY TYPES °#PEOPLE #PEOPLE/SHIFI #SEATS INDUSTRIAL WASTE:Yey or No
LOT SIZE�Qs .`r3 TYPE WATER SUPPLY LA DESIGN WASTEWATER FLOW(GPD) 40 NEW SITEREPAIR SITE +'
I
SYSTEM SPECIFICATIONS: TANK SIZEI
1O—H—'QGAL. PUMP TANK GAL. TRENCH WIDTH _ ROCK DEPTH LINEAR FT
s
OTHER ti
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT h
a
—78 i
.Zb
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTYIHEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:307 9:30 A.M.OR 1:00-1:30 P.M.ON T`HE DAY.OF INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: --V•S,3�
la ops
40PEn0NPERM1'TBY-:
AUTHORIZATIONNO. 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 NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
-c r� , `.� ,�� .rr t.`.�.� n ..:t„- �v—. „ ' ''...c tint{ ,.. ..., .. "✓ .t . .. ... 1-.- ,... .,-,. ,, ,rc+"`q.:�O\
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permitfee s
Name ` ,.{'
Subdivision Name:
Directions to property: r "' �` Section: _ Lot:
, IMPROVEMENT
PERMIT Tax Office PIN:# t
_ Road Name. �t,s A •4 ,,;:<, , : ,;Zip. 0
**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
l I PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
��I�,ESIDENTIAL SPECIFICATION:BUILDING TYPE' c;sem.#BEDROOMS �1 #BATHS S'-L_ #OCCUPANTS GARBAGE DISPOSAL:Yes o4,�To)
COMMERCIAL SPECIFICATION: FACILITY TYPE ^#PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes yr No
LOT SIZE 4]S s.ra TYPE WATER SUPPLY 2> DESIGN WASTEWATER FLOW(GPD) 0 NEWSITE riREPAIR SITE
t � 150
SYSTEM SPECIFICATIONS: TANK SIZE bQQ GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH f LINEAR FT
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r-
1rr �b
' r
L>
-CONTACT
.2b
s
-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.
OPERATION PERMIT ~-�' �
S�STEM INSTALLED BY: 1 S0`Z1J'1k
0 V.S
�1 �( sot++
too� ._� •, '
r ,
ry
AUTHORIZATION NO.� OPE TION 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 130A7,SECTION.1900'`SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
i GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
<c -
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER -� L 1
ADDRESS 1 ` A a S� N etl SUBDIVISION NAME
AN) C ,���� LOT#
DIRECTIONS TO SITE 601
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY v-\,� NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY � SPECIFY PROBLEM OCCURRING J--4�
DATE REQUESTED " ��_ 1 INFOR N TAKEN BY
This is to certify that the information provided is correct to the best of y knowle ge,and that I nderstand I responsible fo II arges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGE
Rev.1/93