P1676A Fairfield Rd �_ mow:-:!T s�'.'•.4v_ _; *..p
AUTHORIZATION NO 9. 6 DAME COUNTY HEALTH DEPARTMENT;.'
1 PROPERTY INFORMATION
Environmental Health Sectiones-., ,
"'Permittee's '} P.O."Box 848
Name:. ,1 Mocksville,NC 27028 Subdivision Name:
Phone# 33677517'87601-
Directions to property: i f ; ' 7 ,Section: Lot:
AUTHORIZATION FOR..
,,� WASTEWATER ,
� r�j ' r�rt SYSTEM CONSTRUCTION Tax Office PIN:# -
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 BuildingPerrruts.This Form/Autlionzation Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)'
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER C
TI STE ONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.:°.
ENVIRONMENTAL HEALTH SPECIALIST, DATE ISSUED
4 +• tv x.�.; 4 r - +- j �1'r+ f''F aVF rwi,�.�� ,.�, .i1,. • ��,.� . .. ,'.` .. ?s �.: - r- 'r
7 A DAVIE COUNTY HEALTH DEPARTMENTPW
w - TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
�"Permittee's
Name: / Subdivision Name:
Directions to property: f" t .' Sechon Lot:
EMPROVEMENT
PERMIT Tax Office PIN:# _
- Road Name 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
constructionfinstallation 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
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.. : .
RESIDENTIAL SPECIFICATION:BUILDING TYPE f*I #BEDROOMS �_#BATHS #OCCUPANTS GARBAGE
DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
/SAI
LOT SIZE TYPE WATER SUPPLY( DESIGN WASTEWATER FLOW(GPD) NEW SITE ! REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZF�L GAL. PUMP TANK GAL. .TRENCH WIDTH 6 ROCK DEPTH LINEAR
OTHER"
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*APPROVED EFFLUENT FILTER* *RISER(S) IF 6" BELOW FINISHED GRADE*
ei1 '
r
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTIJ HEALDEPARTMENT FOR FINAL INSPECTION OF THISSYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE D Y INSTALLATION.TELEPHONE#IS(X t x 1 iE14St
OPERATION PERMIT
SYSTEM INS LLED BY:
A
CX1
AUTHORIZATION N0. YOPERATION 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 05/96(Revised)
u.C.f' ,.r.,� � rc�Y, :...t'iJs:�r..s,;,�.;,t:,,zsc,�r�<w:,}'v ,i, . .,°�'�i`,�ry;'��-':{�"��`i,t .r r.i:•-:; ..:,i.4.;' ' a .. �•.•i .�-1. ,,,si .,�.,,..y m'.:y�l:•.;t:.. ` �/,: h.,..
DAVIE COUNTY HEALTHiPARTMENT 1�`'" ,...f-co
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Natiie;} Subdivision Name:
Directions to'property: Section: Lot:
IMPROVEMENT
=" PERMIT Tax Office PIN:#
Road Name: 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)
***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.
RESIDENTIAL SPECIFICATION:BUILDING TYPE If) 4- #BEDROOMS_„�#BATHS_�#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL;WASTE:Yes or No
LOT SIZE t t TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE :'f REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE,- /b GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH/—-+ LINEARVT..
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
RPPR(3VED EFFLUBIT FILTER* *RISER(S) IF 611 BELOW FINISHED GRADE*
44
\E=
FFd ,
7�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HE&III DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE D Y 00 INSTALLATION.TELEPHONE#IS(?Rf#f1t
OPERATION PERMIT q r
SYSTEM INS LED BY:
AUTHORIZATION NO. &'lle A0PERATIONPERMrr BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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 05/96(Revised)
7
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
�t PO Box 848/210 Hospital Street
a '< Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑
Name: �9` � !/ Phone Number: IJ. V-1:11 � (Home)
Mailing Address: J��.2 /- �lE� �e �O dQ� (Work)
Detailleed'' Directions To Site:
(9��.01 n
Q/ � /Z7ldi
,
Property Address: �
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: y lid �c/�' /� Type Of Dwelling: !/
Date System Installed(Month/Day/Year;;No
? Number Of Bedrooms: c`Z Number Of People: �-
2
Is The Dwelling Currently Vacant? Yes ❑ If Yes,For How Long? •
Any Known Problems?Yves❑ No Z If Yes,Explain: J
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling: l� 'L/. Number Of Bedrooms: Number Of People:
Requested By: PaA-"z2 &," Date Requested: c2- 2-n�Z6
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved
Comments:
i
Environmental Health Specialist Date 4�)
*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: n Received By:
Account #: 7 Zr Invoice #: Z2 6l
DAVIE COUNTY HEALTH DEPARTMENT Fr =r
r Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville,NC 27028
G
Phone: (336)751-8760
r
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION iiName: GI ` �-// Phone Number: ,M 77I J/�� (Home)
Mailing Address: `��.2 /-mfr �� �O!1 (Work)
Detailed• Directions To Site: led,
N'L i `L�' /Pl
Property Address: j i'=
Please Fill In The Following Inforination About Tl a Existing Dwelling.
Name System Installed Under: �G��� � j Type Of Dwelling:
Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People: ;
Is The Dwelling Currently Vacant? Yes No❑ If Yes,For How Long? .
ti
Any Known Problems?Yes❑ Nop
�If Yes,Explain:
tr
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling: //�Y, f/ Number Of Bedrooms: Number Of People:
Requested By: Date Requested: r- f
(Signature)
For Environmental Health Office Use Only r
Approved ❑ Disapproved 01",
Comments:-, c" .iY`'• /r' a t r� �J� �/
Environmental Health Specialist Date 0.::;-
✓ "\ :tel: '"-__�~'E+'� � '` r� .a°'r%,'«f"� `t/
*The signing of this foam by,t]Ke Envirdhmental Health Staff is in iio way intended,nor sho'&d b&&k6f'&slal'
guarantee(extended QAimited)that ttie pi site wastewater system will function properly fo any given period of time.
Payment: Cash 0N.Check[�Money Oider❑ # ;-%'` Amount: $ Date:-
Paid
aterPaid By: tsry Received„By:-
Account #: s 27r Invoice #: