2166 Hwy 64W (2)f r y,f1M1¢ �..: r'. J'r:n-�[s �' . .i`,. i :. � t ,....;�, . •:.Y.i • ?.' .t 1,' ; .: ,'. ',�_,..- u.
permittee s7' DA IE COUNTY HEALTH DEPARTMENT fes,// /�Z_
Name: �/ ' ` `s`� r Environmental Health Section PR(JPERTY INFORMATION
j - P.O. Box848.
Direcfions to property i,1, Mocksville, NC 27028 ., , Subdivision Name:
_ a
Fs Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION. FOR
�iWASTEWATER
�'r��/� f Tax Office PIN:# - -
'SYSTEM CONSTRUCTION
AUTHORIZATION NO: 2 0 6 Road Name ' �ip:
**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 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 CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST' DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE-# BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE / # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �,�� TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
:SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK —GAL. TRENCH WIDTH —?Z "'ROCK DEPTH,V LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: . �u
1
*'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 (336)751-8760.
r
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION N � OPERATION 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 02102 (Revised)
PerrWttets' DAVIE COUNTY HEALTH DEPARTMENT
Environmental.Hea1 h Section
PR ERTY INFORMATION
�. P.O. qox 848
,Due ions tb ,,+'` property - r'i,.4 6Z Mocksvlllr, NC 27028 Subdivision Name:
A„�„�! � ._ ��,'-.��___.---- --Phone #: 356-751-8760
_.
_ .
_l�.. Section: Lot:
/-AUTHORIZATION FOR
WASTEWATER
t ,'''' t' �'� -" J / fi r•� t - -
—�' SYSTEM CONSTRUCTIONTax Office PIN:#
0 •
'. (,1
_AUTHORIZATION NO: A "`� '� Road Nameip:
" **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 FomVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(Incompliance 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 .
RESIDENTIAL SPECIFICATION: BUILDING TYPE 0 "/# BEDROOMS # BATHS . # OCCUPANTS'_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLt' 1--1- # PEOPLE/SHIFT # SEATS - INDUSTRIAL_ WASTE: Yes or No
S'
' LOT SIZE' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONSc TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHROCK DEPTH42L LINEAR FT. �L
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: LJ
1
**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 (336)751-8760. .
OPERATION PERMIT „
SYSTEM INSTALLED BY: -
AUTHORIZATION N OPERATION PERMIT BY: s DATE: e! / n� '
"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:
D= 02102 (Revised)
t
OUNTY HEALTH DEPARTMENT
Dvironmental Health Section
O Box 848/210 Hospital Street -
4 Mocksville, NC 27028
Phone: (336)751-8760
�j
C
't(_ -
ucv J-
t f y
��48'DI�ATER CERTIFICATION FOR DWELLING
�t��ne) EPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Number: `7 9�'Z!>,3 - (Home)
(Work)
Detailed Directions To Site: �0 S S AOct d lgat-lc/
Property Address: 2c` WC
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: Dwa1/y► Type Of Dwelling: S"�A* ie
Date System Installed(Month/ Day/ Year): b — %2 _Number Of Bedrooms:—.2—Number Of People. 3
Is The Dwelling Currently Vacant? Yes ❑ No Ve" If Yes, For How Long?
Any Known Problems? Yes ❑ No t2' If Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: DO t b [e w 1 JQ Number Of Bedrooms: Number Of People:_ _
Requested By: Yl J \S e Date Requested: O-13�--
(Signatur )
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments: ///O.%i4i I/ /'�;?In';?7, �Ll L� .
Environmental Health Specialist Date
*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: CashE Check G Money Order,- r Amount: S Date:
Paid By: Received By:
Account ' Invoice:y _
AU ORIZ 'ION No: DAVIE COUNTY HEALTH DEPARTMENT
.�' 1 �? � � Environmental Health Section PROPERTY INFORMATION
Permittee'.s , P.O. Box 848
Dame: Mocksville, NC 27028 a Subdivision Name:
rV Phone #: 704-634-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:
SYSTEM CONSTRUCTION 9 -
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 Building Permits. This Form/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)
I ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
4�61 ZAIS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTHSPECIALIST DATE ISSUED
_..:_:..RESIDENTIAL SPECIFICATION: BUIL LL._ -.._...._.:..,._.:_.._..w :._ __ ._.;._....:.::�.�.. •.:...:.:,...: - ti..._.�.,�.:...:�.�_,.....:_.__.,._.........__ . ..__., _ .
DING TYPE_ # BEDROOMS — # BATHS # OCCUPANTS GARBAGE DISPOSAL. Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
fit
LOT SIZE TYPE WATER SUPPLY K " DESIGN WASTEWATER FLOW (GPD) NEW SITE �� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEIMd GAL. PUMP TANK GAL. TRENCH WIDTH �G ROCK DEPTH A2 LINEAR FT. (�d G
OTHER
i
i REQUIRED SITE MODIFICATIONS/CONDITIONS:
i X
"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
C \�
:::::::::TALLEDY:
AUTHORIZATION NO. V OPERATION PERMIT BY: DATE: v "
"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.
i
DCHD 05196 (Revised)