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`UTHORqZATION NO: 0947 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's P.O.Box 848
Name: %-AO
Mocksville,NC 27028 Subdivision Name:
- f Phone#:704-634-8760
Directions to property: %: Section: Lot:'
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
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Road Name: :� O
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie CouYy 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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS..
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
1 !�'�.�(4T �6 '1i"" r,�_..-r::, `e+tk , i i;'E�'.:;,,,yp.^r:siJ t �,.N'5,��'`iY�'yr�,.fy� vai .� ,t�-r tf{�it i.�°I x✓t 1 ..r."1 v4 i�,��:�yaai�Y"Y.4 s; f•<,f!'ij�i"..h.. �.�'1 ,,.r t-+.;
4 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
PeriFiiftee's� �• -
Name: Subdivision Name:
Drre5fidns-to Property:. •,a,. �`', ,l r Section: Lot:
r IMPROVEMENT
' PERMIT Tax Office PIN:# - -
Road Name: r
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank qstem 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)
. r ***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 #BEDROOMS 7 #BATHS 4-A #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY_,4- DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH -"7 /O�ROCK DEP"I'$� LINEAR Fr
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
` IMPROVEMENT PERMIT LAYOUT
"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 WQ
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. OPERATION PERMIT BY: ' An.T DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED INCOMPLIANCE
WITH ARTICLE I OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 6/96(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
✓_, IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
PeFmitiee's
Name: Subdivision Name:
Directions to property: Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
Road Name: y :s
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank qstem 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�'/N #BEDROOMS =;Z—#BATHS a #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. l�
SYSTEM SPECIFICATIONS: TANK SIZE. GAL. PUMP TANK GAL. TRENCH WIDTH.--�'/ �ROCK DEPTH� LINEAR FT,-fz
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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IMPROVEMENT PERMIT LAYOUT
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"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 � �
SYSTEM INSTALLED BY: '
50 'xZq"
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rooIt.�
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AUTHORIZATION NO.v ' q,7OPERATION PERMIT BY: "`����A�+-�
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 SATISFACTOMY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
/� WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME !l/e ,/�. /Ij1'1 h PHONE NUMBER
ADDRESS ��. /c-� SUBDIVISION NAME
�// SUBDIVISION LOT#
DIRECTIONS TO SITE �:(YQZ/r�b/I .e(
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY