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674 Hwy 801S (2)**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 % [,,,1 � + IS VALID FOR A PERIOD OF FIVE YEARS. 'AL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE S # BEDROOMS --/—/ # BATHS # OCCUPANTS _[_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE'/ /4 'TYPE WATER SUPPLY `U DESIGN WASTEWATER FLOW (GPD) + C/ NEW SITE REPAIR SITE C-" t 1 � �/` `� It ' SYSTEM SPECIFICATIONS: TANK SIZE X I GAL. "PUMP TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT: L' G r OTHER x U� i+s stated in 15A NCAC 16A.19£g(5) &C u c u rA QUIRED SITE MODIFICATIONS/CONDITIONS: accepted Systeme may also by ti n .V tUC � Cr /VruS (hri IMPROVEMENT PERMIT LAYOUT r�� �� c e - i C(i / G �� ..='y (/ ✓' �"',' 'Y7 l( r> I f7 K 5 f fICC C-144 /C)% r 3 . ! FORFINAL 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 ` s. SYSTEM INSTALLED BY: rr R iA Q%4o f irs1 / r��J (r ` foo � � 16 CA AUTHORIZATION NO.v `� 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. j.t DCHD 07!02 (Revised) � ✓�(j f q _- Penni ttee's�� � 1� ,�, � � �� �t DAME COnv�ronmeTY ntalALTH DEPARTMENT Name: ea1H e PROPERTY INFORMATION `' P.O. Box 848 •- ~ Directions to property: Mocksville, NC 27028 Subdivision Name: r" J Phone #: 336-751-8760 Section: Lot: ir^I t=�� , y,sat AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - ,J SYSTEM CONSTRUCTION j AUTHORIZATION NO: A /' 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) /***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION % [,,,1 � + IS VALID FOR A PERIOD OF FIVE YEARS. 'AL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE S # BEDROOMS --/—/ # BATHS # OCCUPANTS _[_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE'/ /4 'TYPE WATER SUPPLY `U DESIGN WASTEWATER FLOW (GPD) + C/ NEW SITE REPAIR SITE C-" t 1 � �/` `� It ' SYSTEM SPECIFICATIONS: TANK SIZE X I GAL. "PUMP TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT: L' G r OTHER x U� i+s stated in 15A NCAC 16A.19£g(5) &C u c u rA QUIRED SITE MODIFICATIONS/CONDITIONS: accepted Systeme may also by ti n .V tUC � Cr /VruS (hri IMPROVEMENT PERMIT LAYOUT r�� �� c e - i C(i / G �� ..='y (/ ✓' �"',' 'Y7 l( r> I f7 K 5 f fICC C-144 /C)% r 3 . ! FORFINAL 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 ` s. SYSTEM INSTALLED BY: rr R iA Q%4o f irs1 / r��J (r ` foo � � 16 CA AUTHORIZATION NO.v `� 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. j.t DCHD 07!02 (Revised) � ✓�(j f q . �, .-. -::'v � : �µ -...:, r ,ya,l:.::.. ..,,-, ' Y i t . ,,,.y,",� •.-;.>"n, a � a,.�:.' ` "v; v-. a - � ... r�.:.... s - x N. .. , r ^ j � `- 1'a;9 �i?& ittee'�s', y�l , .I ��: :'� aDAVIE COUNT�mHEA Ymental L8H DEPARTMENT PROPERTY INFORMATION i.., i,- t y P.O. Box 848 -' Direc�ionj to property: -- Mocksville, NC 27028 Subdivision Name: (( Phone #: 336-751-8760 Section: Lot: 1 AUTHORIZATION FOR `s WASTEWATER Office SYSTEM CONSTRUCTION Tax PIN:# - - AUTHORIZATION NO: 003051 A' `' r r 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) �p , .•. z ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION «~ '' •'' >* .r r-�r (; [„: IS VALID FOR A PERIOD OF FIVE YEARS. ENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE L` # BEDROOMS # BATHS - • #OCCUPANTS Ll GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE' r TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) t'i NEW SITE REPAIR SITE t --- SYSTEM SPECIFICATIONS: TANKSIZE GAL. PUMP TANK GAL. TRENCH WIDTH �i C r r YROCK DEPTH LINEAR FT. L' i s t OTHER t .. ;REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT Z, - lA4 r.'r./� i i 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. c .� OPERATION PERMIT SYSTEM INSTALLED BY: B r: w AA_ ��C, V3 rp Ch 3U , 10 21 )A qn,Iolo .7 15 t 1 AUTHORIZATION NO. V d 'SQ 5 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 07/02 (Revised)iI %;`' ✓} 1 .'�' rriuea' Ca.1.t a�.:�o<Jt. w%1ti be lvrlGvO -sem w��t nuQ, tv r�,r.�=-Strom /'� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION r APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME_N�k � b-tn� T[rvo PHONE NUMBER 334- 490' 203 ADDRESS 4W 8o (.s AJ o- SUBDIVISION NAME &2 G-0 90(5 LOT # DIRECTIONS TO SITE I yk " T ? � ?b I - h ow., ^, IZ'- - DaV- V aL6 C�►, +'� �- OWti rti- Uh,J eau DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER a Z,6 A+b TYPE FACILITY H NUMBER BEDROOMS T NUMBER PEOPLE SERVED 7 TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING S'L.t-(' c- t n - l ►. ?A V.-�cJ �` i --t t ' Cx POT S N r v add SvtJ .nn of A.4.0 DATE REQUESTED W lr'(a INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. ,/93 L I understand I am respor%ible for all charges incurred from this application. 7(/'/d '., ' Gv'(Q )"e F 4i fI ]' .k 9 c SlE4Mdi F t ,. � � � � ✓ ttaw ✓' 1= Ltx. 'm.."t„ '1 ,:t, .'.P P ,. _ DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION w .NOTE- Issued in Compliance With Article 11 of G.S. Chapter 130a f ' + Sanitary Sewage Sys/tams ) Permit Number Name Date _.'"'"'%� N2 4 9 Location/i✓'��+ .°� s* a1�.,/,<` Sf- %� , �%rr'•�-✓f .�~I" .,j'.�'J Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business __ Industry No. Bedrooms _=1° No. Baths No. in Family Public Assembly Other Garbage Disposal YES ❑ NO 0- Specifications for System: Auto Dish Washer YES 4 NO ❑ Auto Wash Ma^hine YES j NO ❑ Type Water Supply C *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. f i Improvements permit by —, 10 f• *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by `� 5 �-. C �' �-�� ��,>•. Certificateo Completion Date h %� *The signing of this certificate shall indicate that the systefn described above has been installed in compliance with #L— �4—4—eic cnt fnrth in the ahnvP regulation. but shall in NO way be taken as a guarantee that the system will function , ° DAVIE' COUNTY HEALTH DEPARTMENT -v'- •, IMPROVEMENTS PERMIT AND. CERTIFICATE .OF COMPLETION ` *NOTEAssued in Compliance With Article If of G.S. Chapter 130a 2.,700(;. Sanitary Sewage Systems Permit Number Name O'X%� 6 VZ � i ✓Date N� Location ,� + �' ��' %� r_J.�r ;�` ✓ sf fi �" �, �'� .r r',.� (�j Subdivision Name Lot No. Sec. or Block No. Lot Size`! '' Houser''v Mobile Home __,___ _ Business Speculation No. Bedrooms No. Baths / No. in Family Garbage Disposal YES [:]NO p Specifications for System: Auto Dish Washer. YES ❑ NO Auto Wash Ma shine YES ❑ NO Q�� Type Water Supply; *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. Improvements permit by�'�` *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 day of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Insta led by u Certificate of Completion �, - Date '{� </ .The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time.. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/ Site Evaluation APPLICANT INFORMATION Water Supply: On -Site Well Community Evaluation By: Auger Boring i� Pit ,•••• it � •NuI,�1�•),� ® 60(5 C. a - Public ✓ Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture groupC Consistence ' Structure Mineralogy-� HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION PIS LONG-TERM ACCEPTANCE RATE , �? SITE CLASSIFICATION: 5 LONG-TERM ACCEPTANCE RATE:_ 77 REMARKS: EVALUATION BY: _26 OTHER(S) PRESENT: c� LEGEND Landscape Position R - Ridge _S - Shoulder L - Linear slope. FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay ON I T NCR )41St VFR - Very. friable FR - Friable FI - Firm VFI Very firm , EFI - Extremely firm wit NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Rtructure SC - Single grain M - Massive CR - Crumb GR - Granular ABK -Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed lYlzt,r.� Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate gal/day/ft2 DCHD 05105 (Revised) a j �� "„�aaV���;4 4f; �� 5 -y,. � �_.,�� �>.wj,.._�wp�..a,,e�i;1; "F. ,:,y �.,,r.:.;�< <. 5,. �.:-• •-i.,w. ..r ., ._ `-..,""/ -,St, DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND 'CERTIFICATE OF COMPLETION r `* NOTE51ssued in Compliance With Article 11 of G.S. Chapter 130a r `�'anitary Sewage Systems Permit Number Nae �� /�. /ff �/ d ti J / Date �"�`�%' N - 7457 Locati n �� ��` SC%/wn.v Subdivision Name Lot No. Sec. or Block No. Lot Size - House _—Lee, Mobile Home —T Business , Industry No. Bedrooms -r No. Baths No. in Family/r'l f Public Assembly Other Garbage Disposal YES ❑ NO [a' Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma^hine YES NO ❑ -Type Water Supply — ---- *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. S Improvements perm "Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Certificate c Com letion Date The signing of this certificate shall indicate that the syste described above has been installed in compliance with \ the standards set forth in the above regulation, but shall in O way be taken as a guarantee that the system will function `,z. ;satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit quested By j�.�. MAR - 31994 e /_ ,,/. _ I -------------- 9�Mailing Address Home Phone l� Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation Septic Tank Installation Permit 4. System to Serve: ArHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision No. of People l/ No. of Bedrooms 7 _ No. of Bathrooms •� Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: , Public ❑ Private ❑ Community 8. Property Dimensions l �Ir/?�O Sewage Disposal Contracto2i 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No Section . Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing JXI Washing Machine Pe Dishwasher ❑ Garbage Disposal If yes, what type? "NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property:�5' r l� ��o� O� This is to certify that the information provided is co rre to th best of my knowledge, and I understand I am responsible for all charges incurred f m this application. 2 K DATE 41GNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: Imo. OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (1193) .J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/Site Evaluation NAME' ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE 449W LOCATION OF SITE) Water Supply: On -Site Well Community Public-' Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position ,L G Sloe % -7- 2HORIZON HORIZONI DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ( , SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: --171 REMARKS: DCHD(01-901 EVALUATED BY: 16k - OTHER(S) PRESENT: LEGEND. Landscape Position R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope Texture S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty clay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay I SIC -Silty clay C -Clay CONSISTENCE Moist VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic Structure SC -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors with chroma 2 or less Classification S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 ■■.■■■..■■■■■.■■■■■.■■■■■■■.■■.■■esu.■.....■■..■■.■■■■...■■■■'' ..■ ■■■■.■■■..■■...■..■..■.■■■.■../■■■■........�.■■■..■.■../........■■ ■■■■■■■■■■■■■■■■■■■■■.■■■■■■■/■■/■■■■.■■■■■■■■■■■■■■■■■.■■■■e■■■■ ■...............■...■..■...■..■■■.■......�■...�■..■■..■ .■■.■.�e■ OMEN 0 ■............■....■■■■.■.!■.....■........■1........■■■.■■�■...■■..■/ MENNENMMMMMM �i=ii:iiii�.�i'fiiiiii�ii■'ii�■■� � 'SiiiiiiMMUMMOMEMME �MMMMMMEM.�iiiiiis.Ui ■...■.■..■.■......■..■.■.�.�■..i■■�■..u.C..■.■. ft.■.e■. ■.■..■■. ■■■■■■■■■■■■..■■.■■■■■■....■■.■.■.■■■.�.. ■..■■. ■R■■■■■..■■■..■■ ■■■.■■■.■..■■■■■./■■■■■■■.■■■I:1■■ ■■■■ film■ WE .. ■ ■■ ■■■■■■■ ■■.■■■■■■■.■■.■■■■■.■■..■■.■.■■�.�i.■■ fma■■■m. ........n■■ ■.■■ ■■■■..■■■.■■.■■.■.■■■■e■■...■.■.■....._■�.....■.�if� ■...e■■..■■'�■... ............■.■......■n..■...■.■........n. no ■ M'-\�'HEMMEME IM :�'f�:�0 �:H:C::M:::::f,::. .................■.............. -..... .... ■■■■■.■■■■.■■■■■■ .............................■■...��_..'■�'.■�■.■ i n■■..■■■.n.■.■■ ii'=iiii= '■■'iiiiiii NoM . iieii■oiONE fN i MiiiiiiiHii■iiiMMM MEMO s..■..■...■■■■.■.■■.■■.■■■■■...■�i■■■■■■■_.■.■■u■.■■■■■■■■■e■.■■■ ■■■■■.■■■■■■.■■.■■■.■■■■■.■■■/■u...■.... ■n.■n..■■u■■.■.■■.■.■ MOMMMEM'N'M ■ f1Nn NONE� M■OMMEMEEMN■MEM ..■■■■■■...■■■■.■■■. .■■■■.■■..■U'■■■■..................■e■e■■■■. ................................ ................................ .................................................................. .................................................................. ■/■■ ■■■■■■N■■■■■e■■■■■■■.■■.■■ ■.■■..■■■■■■■■■■■■■■.a■■■■u■.■■ Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753.6780 Fax: (336) — 751- 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: 114 z T— + l wm R e , Phone Number (Home) Mailing Address:fD /TftVV y ?_0 J S- (Work) A6 Y/ -M t: N G '170 Z Detailed Directions To Site: L's I$ % 7V fO Sdw7y. ta.S i:- �iR. C7'Ly A-CA20 S 5 !� 1Srn4___0r P�r U,ND 611 Property Address: Please kill In The Following Information About The EXISTING Facility: Name System Installed Under: '90 UN- ` d•IL.,r N- 400 Type Of Facility: Date System Installed (Montb/Date/Year): Zo t Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes .No If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEWFacility: . Type Of Facility: Number Of Bedrooms: Number of People Requested By: Date Requested: (Signature) For Environmental Health Office Use Only Approv . Disapproved / y 7!%Q�� Comments: illC �pt-� Environmental Health Specialist ate: _: 3 —t"& — (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Ch Money Order #'/- IAmount:$ /0 V, w Date: Paid By: /%ltl,X Qool .rGLt,�• " �ke� nrtiL Received By: Account 0.. __Invoice #: d