1805 Farmington Rd fo��E ``e ti - �; o r t'sf^r s 4•`N 53'�'i i`:t x'r rd Ta x;,s �, r�-r .�, ;s .; ; ...r'. Y' ='- ''E'' r(/Ya
_'AUTHG3,~IZATION NO: 0 4 41' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION V0
Permittee's P.O:Box 848, 'Z•.
Name: Mocicsville,NC 27028 Subdivision Name:
Phone#:704-634-8760
. D rections to property: 4 - Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM.CONSTRUCTION
Road Name: 1r�Y--�Zip:
**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 applying for Building Peimits.
(In compliance with Article'l I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems),
_ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION,
g .�a`}.,�, •� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED_
f t '.""e
S,•
Air DAME COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION vt7
Subdivision Rame:
�� `
Directions to property: � r> 1=w �.,;, -� Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
x.. r, ` • '� sr» �s- Road Name T �:r :s.�t..A Zip: -»i '•,
**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 obuilding 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 .h �#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes o No
COMMERCIAL SPECIFICATION: FACILITY TYPE'_ #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
L'OT SIZE ti s•"o TYPE WATER SUPPLY �-"' DESIGN WASTEWATER FLOW(GPD) NEW SITE.- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE!Oo_0GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH J V LINEAR Fr. "0
OTHER
REQUIRED SITE MODIFICATIONS/CONDPCYONS:
IMPROVEMENT PERMIT LAYOUT
N � ��
v �
r
F
i
"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)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
f
B
o �
niu
AUTHORIZATION NO. OPERATION PERMIT BY: DATEJ O 1 _
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T 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)
�ti .. v V � ,� ti l �S C•,��•.h."f, 1 . a .
� � . . • � �, `�/—"1�
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION . Uv
I '2,
yNameY '� ; . Subdivision1ame:
Directions to property: Section: Lot:
i
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: _ . u: r, ;'o 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..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
�•„.; y ; 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 #BEDROOMS #BATHS j #OCCUPANTSGARBAGE DISPOSAL:Yes o(N ,
-...
COMMERCIAL SPECIFICATION: FACILITY,TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE T tzsf�-'r' TYPE WATER SUPPLY `—!' DESIGN WASTEWATER FLOW(GPD) �� NEW SITE REPAIR SITE •'
SYSTEM SPECIFICATIONS: TANK SIZE 1 Oc7 0 GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH j LINEAR Fr. � t
• a
OTHER � . \ '•,.� �, � —
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
A,
!'b
1 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)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY: i ^r-��► �ti
B ;
r
AUTHORIZATION NO. L\4 .., OPERATION PERMIT BY: �a; DATE:�O �—�7
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T AT THE SYSTEM DESCRIBED 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 SATISFAC'T'ORILY FOR ANY GIVEN PERIOD OF TIME.
16M 05/96(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME `� .� PHONE NUMBER A - 3163
ADDRESSUBDIVISION NAME
10
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED Ho NAME SYSTEM INSTALLED UNDER �` kt \
TYPE FACILITY � NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED -�� INFORMATION TAKEN BY C ��
This is to certify that the Information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93