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1995 Hwy 801S- DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 REPAIR OPERATION PERMIT Account #: 990002964 Tax PIWEH M C805OA0008 Billed To: A Full Measure Catering Subdivision Info Reference Name: REPAIR PERMIT Location/Address: 1995 NC Highway 801 S.-27006 Proposed Facility-., Catering Facility -Repair Property Size: 0:343 Acre ATC Number: 5898 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type: , —LIJOR S.T. Manufacturer `� 1 -- Tank Date 2-Z Tank Size /10C)' Pump Tank Size /" Bedrooms System Installed By j R%'l/ U Inspector#: Date: GPS Coordinate: v l�tiv'`v i Environmental Health Specialist: DCHD 11/06 (Revised) Date:�_j�G��Z _LN001de* 810M DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 REPAIR IMPROVEMENT PERMIT AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002964 Billed To: A Full Measure Catering Reference Name: REPAIR PERMIT Proposed, Facility-, Catering Facility -Repair Tax PIN/EH #: C805OA0008 Subdivision Info: LocationiAddress:',:1995 NC Highway 801 S.-27006 Properly Size: ; ' :0:343 Acre Site Type: Repair ( ) Expansion ATC Number: 5898 **NOTE** This IP/ Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS IP/ AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS.This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms //��# Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility TypeQ%AyVQlY ak V& People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: IDdCounty/City ❑Well ❑Community Well. System Specifications: Design Wastewater Flow (GPD) Tank Size_�tL. Pump Tank GAL. Trench Width ! Max. Trench Depth /_ Rock Depth Linear Ft._�. Site Modifications/Conditions/Other: aA `7 Contact the Davie County Environmental Heal Section for final inspection of .this system between 8:30 — 9:30a.m. on the day i DCHD 11 /06 (Revised) GoMAPS -. Davie County NC Public Access 0WATERSHED_STRUCTURES , WATER -BODIES COUNTY -BOUNDARY ADDRESS �! DRIVES STREETS X' RAILROAD tk1 -CENTERLINE PARCELS CITY -LIMITS BERMUDA RUN ECOOLEEMEE E] DAVIE COUNTY EJMOCKSVILLE nccounties DAVIE <all other values> ***WARNING: THIS IS NOT A SURVEY!*** Tuesday, March 27 2012 This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned 'public primary information sources should be consulted for verification of the information contained on this map. The County and mapping company assume no legal responsibility for the information contained on this map. **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 I 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 C6N�1 . COMMERCIAL SPECIFICATION: FACILITY TYPE S}ot # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY `CK� ` DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE .A i SYSTEM SPECIFICATIONS: TANK SIZE to 060 GAL. PUMP TANK ,e!!!!� GAL. TRENCH WIDTH ROCK DaEPTH 4 LINEAR Fr. �U ' d OTHER tkfj w 0 f Gt 0 O� �. c d- f CA cn c i, c0 yh a N l o t to e LA -15 A ell co cc p V -u7 ..a 0( o N y REQUIRED SITE MODIFICATIONS/CONDITIONS: 1'06 r— 5 i ut k 141 a rj7` k U U- LS" d e d 5 I '✓i e- / I1 'S - er /1;0 Q IMPROVEMENT PERMIT LAYOUT u r. B r—I C tAkC -+✓ uG��,vcajP C} K o C' yv�►lS� b� CLe0K r•c� ©c,rta� 10 CYcl wl n�,.j yvo��; e k, C� �aK// rho y Al e c rr 45a ✓ � SiA K drtri�A CS� Yhl��j� �K. i'c� Sepi;C S[f5/Pr-r-i ) 3o -iCj b.c r-eaC1'-U.Aa-A WiF1-ew fiP,c- aN 4n FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT - i'y�A- C�^ � 5 '�� eoo G� SYSTEM INSTALLED BY: S i (Qd �� (J --e 0/ iK/a bid cJ 5'-Q�'�►'� s Y s�,�.`' \ > rsu �— «-�` `-tot, ► , tgc 6 j 1 C AUTHORIZATION NO. db ? P1cRATION PERMIT BY: ( S /% 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. DCHDO?/02(Revised)�-�(-55/1d yr . 1 fy I c_. DAV.IE-GQUNTY HEALTH DEPARTMENT \ Name:. L c\, �0 0 .+ c I �y c. k.. i 1 r 01 c. Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: Mocksville, NC 27028 Subdivision Name: ra e4� Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR t, WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# - - AUTHORIZATION NO: 002752 A Road Name: � Zip: C C) **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 I 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 C6N�1 . COMMERCIAL SPECIFICATION: FACILITY TYPE S}ot # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY `CK� ` DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE .A i SYSTEM SPECIFICATIONS: TANK SIZE to 060 GAL. PUMP TANK ,e!!!!� GAL. TRENCH WIDTH ROCK DaEPTH 4 LINEAR Fr. �U ' d OTHER tkfj w 0 f Gt 0 O� �. c d- f CA cn c i, c0 yh a N l o t to e LA -15 A ell co cc p V -u7 ..a 0( o N y REQUIRED SITE MODIFICATIONS/CONDITIONS: 1'06 r— 5 i ut k 141 a rj7` k U U- LS" d e d 5 I '✓i e- / I1 'S - er /1;0 Q IMPROVEMENT PERMIT LAYOUT u r. B r—I C tAkC -+✓ uG��,vcajP C} K o C' yv�►lS� b� CLe0K r•c� ©c,rta� 10 CYcl wl n�,.j yvo��; e k, C� �aK// rho y Al e c rr 45a ✓ � SiA K drtri�A CS� Yhl��j� �K. i'c� Sepi;C S[f5/Pr-r-i ) 3o -iCj b.c r-eaC1'-U.Aa-A WiF1-ew fiP,c- aN 4n FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT - i'y�A- C�^ � 5 '�� eoo G� SYSTEM INSTALLED BY: S i (Qd �� (J --e 0/ iK/a bid cJ 5'-Q�'�►'� s Y s�,�.`' \ > rsu �— «-�` `-tot, ► , tgc 6 j 1 C AUTHORIZATION NO. db ? P1cRATION PERMIT BY: ( S /% 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. DCHDO?/02(Revised)�-�(-55/1d yr . 1 fy .rr 1- :b- rb. ,.i i Z,.:v A.,, rr .;;w•;..,,{-�:r 1-::i Ys.l'.+"'+` °`"�vy^s.n r4 fay 8.y.'y v'sor t�x.� „hy�y, e•^ w,...,j; rYf,-:..:•vC 6,` ,�.w't t tt i�'4 4.-+a'�rHt.' ,yg•'y, V: �„�;t���. Rem ,iwx�.. � � - DA IF .CQUNTY HEALTH DEPARTMENTLti`,,, r c: c: k i r r r •Env`ironmental Health Section PROPERTY INFORMATIONNamet P.O. Box 848 Directions to property: -t < r' c "# Mock,sville, NC 27028 Subdivision Name: (Phone #: 336-751-8760 •� by a �1..Y rt , t t, r4 t Section: Lot: " ' AUTHORIZATION FOR WASTEWATER; SYSTEM CONSTRUCTION Tax Office PIN:# AUTHORIZATION NO: 002752 A Road Name:I I C? I Zi}G **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pernn ts.•This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 1 I 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 Coo -j . COMMERCIAL SPECIFICATION: FACILITY TYPE SiOI r # PEOPLE_ # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE !� f x19,•.' y rr , SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK �� GAL. TRENCH WIDTH _ _3 G ROCK DEPTH of LI LINEAR FT. dOTHER l �16k. 01 Ctyrri e4 rr( r4uci.r-N liltnV Ltai �A (.tSae)% FG h ifw'L4 c; &A p I ( y REQUIRED SITE MQDIFICATIONS/CONDITIONS:tt Gnn—r I� tjt r r !!�bl A cr ,r .p LAO rl r v S i.� � c r' an G r 44-45 1 r /I.:, IMPROVEMENT PERMIT LAYOUT in nr • -��" tel. ; t~,. � ,� � a/ I d Q ' yv1 tk 4 �j I `� r cJ to r-.Gl Jh� � 3o - �� 01A lO6' L:...�"�u b� f aci.V {cd w(n-tw FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: t P U C—O V n 4Val -/fes D� Q a G AUTHORIZATION NO. 02617 SOI�RATION PERMIT BY: nA r� .�. , ��L ' DATE: 1� 3 —]'moo �d—�- '�. **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 BE TAKEN AS A GUARANTEE THAT THE SYSTEM(WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ncHDovoz (Revi d) "dlf '7 MATION IENT EpARTN PROPERTYINFOR y 11FALT, s t.01) cl Name lies r , 000 Subdivis,." Lot'. 848 0,0 8' t4c 2702 Me Ction*. 4 s 0 MOCV-s,,,. } prf .y xw-auv'+:, k�.:id `t v -.i r«� .is.. -„:-:r �v L - s��,�. -'r.-.,roc:. ;e' -i x i r•--...,..r•,•.r.. ,�,,;;.-\^� �Y: 1E r S ', DA�I� C�QUNTY HEALTH DEPARTMENT S i �pROVEME rNT AND OPERATION PERMITS PROPERTY INFORMATION Permittees~ 1 Name:” Subdivision Name: rte. Section: Lot: " Directions to property:/ s� IMPROVEMENT PERMIT Tax Office PIN:# J9!/�izCC Road Name: i Zip: **NOTE** This Improvement Permit s NOTauthorize the co stiuciion or installation of a septic tank -system or any wastewater. system. An ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRU; qON must be obtained from this Department prior to the construction/installation of a system'or the issuance of a building pernut. (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 <. `SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ENVIRONMENTAL 14EALTIISPECIALIST DATE ISSUED . INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No �L COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY U DESIGN WASTEWATER FLOW (GPD) �A NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE OD GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH A LINEAR FT. 55,-� OTHER S✓; 111114 REQUIRED SITE MODIFICATIONS/CONDITIONS: "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 ROM SX) R6M (336)751-8760 AUTHORIZATION NO. ` OPERATION PERMIT BY: A/., DATE: OCl C1 �I�D "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) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION / WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT NAME �/l L �Ze/' �e�s PHONE NUMBER ADDRESS -//(t-/(,/ 015 , SUBDIVISION NAME SUBDIVISION LOT # DIRECTIONS TO SITE 41ee74__ T ,�,--j DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER SPECIFY PROBLEMS OCCURRING DATE REQUESTED INFORMATION TAKEN BY oil oil a EI _ �... m 56 y r e . z 1 , z R OR 05 £a 1 0 = a AVIE COUNTY HEALTH DEPARTMENT t' U Environmental Health Section r PO Box 848/210 Hospital Street Mocksville, NC 27028 FEB 2 Phone: (336)751-8760 ECd'FIt7CPd^"EP.�FI. T SI ASTEWATER CERTIFICATION FOR DWELLING ec ne) REPLACEMENT ❑ REMODELING Er" RECONNECTION ❑ ��, s �,� .� Name: ' L �r1 � � v i\ � �'�z= � Phone Number: 1 (Home) Mailing Address C' scc 'S ^ � 7 �2 yC (Work) Detailed Directions To Site: i. /I P\6 / (-ca,' J '711?oc �. �i C� �y/�'I,t' T[-,) 1�F c e- 60 h I e F-� Property Please Fill In The Following Information About The Existing Dwelling. 'Z�161w bui Il 06-11 Name System Installed Under: Type Of Dwelling: - Date System Installed(Month/Day/Year): Number Of Bedrooms: r� `Number Of People: C— Is The Dwelling Currently Vacant? Yes /❑ No IIf Yes, For How Long? Any Known Problems? Yes ❑ No Yes, Explain: Please Fill In The Following Information About The New Dwelling. Type Of Dwelling: i e A. el' t i if Number Of Bedrooms: Number Of People: Requested By:. (Signature) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Comments: Requested:,_ `;/ Environmentaf 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: _Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: Paid By: Received By: Account #: Invoice #: