161 Ken Hoots Ln Permittee'�� ' ' DAVIE COUNTY HEALTH DEPARTMENT
Name:�/�1��c7��✓I��cr'lQ>. Environmental Health Section PROPERTY INFORMATION
�� '. � /�rtl m ��. P.O.Box 848
Directions to property: �- Ir 1�1ocksville,NC 27028 Subdivision Name:
�� .�;, � , ��` ,�� � Phone#;336-751-8760
f—,f P�dTt fc �- � �u�/rf � Section: Lot:
' �AUTHORIZATION FOR (��
�n ��1 1:41��-�f/ J7 a.5 S �/-�- i�PL �-+'''t ��� WASTEWATER Tax Office PIN:# 7�u�_ � _ 9��
SYSTF.M CONSTRUCTION �
ALJTHORIZATION NO: ����2 9 r A��'� Roati�l�iame�'�k I/'�G?�� �vZ 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 Counry Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Sec[ion.1900.Sewage Treatment and Disposal Systems)
���f� _ `_l _!���**NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
% IS VAL[D FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
` ,_ , ...� • . s
' Pemiittee-s-•� �• ,� t l , DAVIE COUNTY HEALTH DEPARTMENT
.Name: rQ`1 �`� /V �Gh�d���t'SC���v'• ' Environmental Health Section PROPERTY INFORMATION
�� ( ,S f(G vN �� - P.O. Box 848
Directions to property: � Mocksville,NC 27028 Subdivision Name:
-�' y � I �;. L Phone#; 336-751-8760
`f�b t'�I p'S�U t�tX1 I�*`. �/L- � ���vN + Section: Lot:
d!� u ( _.{.. �AUTHORIZATION FOR
G16�-�V �U 5 S 1 Oa �'Os`� ���'� � WASTEWATER Tax Office PIN:# �g�d_ .3� _�
,�. SYSTF.M CONSTRUCTION r
AUTHORIZATION'NO: O O L�.�9� AO bi (. Ro�d(I�Vame!'�Ll �Od� �vt Zip; ��ll�(� ;
- **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Counry Environmental Health Section prior
to issuance of any Building Permits.This Forni/Authorization Number should be presented to the Davi�"County Building Inspections
Office when applying for Building Permits.
(In compliance with Article l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
A i
�/Ji��" �I�„'�t,-`,,��'***NOTICE***TH1S AUTHORI7_ATION FOR WASTEWATER CONSTRUCTION
'// �� J IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED :
� , i I
RESIDENTIAL SPECIFICATION:BUILDING TYPE �#BEUROOMS � #BATHS� �7 #OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFI�ATION: FACILITY TYPE #PEOPLE #PEOPLEJSHIFi' #SEATS INDUSTRIAL WASTE:Yes or No �
€ /
LOT SIZE I��� TYPE WATER SUPPLY W DESIGN WASTEWATER FLOW(GPD)� NEW SITE REPAIR SITE�,
,� ' //,�- I
SYSTEM SPECIFICATIONS: TANK SIZE �� AL. MP TANK�GAL. TRENCH WIDTH�I_ ROCK DEPTH��'f���INEAR Ff. �Ob
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PF,K��+�(OUT ��� ��.�
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FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE N IS(336)751-8760.
OPERATION PERMIT .
SYSTEM INSTALLED BY:
;.;
. . k:
AUTHORIZATION N0. OPERATION PERMIT BY: DATE:
•*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTfH 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 SATISFACTOgILY FOR ANY GIVEN PERIOD OF TIME.
DC4ID 02/02(Revised)
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Pe�,rmittele,,'s� > ' ��.'f . } p �� DAVIE COUNTY HEALTH DEPARTMENT
_Name: {�U�1 �' y �v�t-h 1���'�d' f X��"d� Environmental Health Section PROPERTY INFORMATION
: �� � � �<t+'H �a - P.O.Box 848
Directions to property: Mocksville,NC 27028 Subdivision Name:
`� � ��iF>�l����cft �:�', l��- i f�ws�tf ,L, Phone#:336-751-8760
Section: Lot:
"� � �}G�'���+U�HORIEWATF.R �R � ��' t� �r
U� �������� �� "� y • f� ��i SYSTF,M CONSTRUCTION Tax Office PIN:# �3��C} - ��" - � �I�`
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AUTHORIZATION NO: �'� ,� L�; Ro�d'Name���� �lGCJ`��" �tz Zip: ��ti�i� ,
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Fo►m/Authorization Number should be presented ro the Davie Counry Building Inspections
_ Office when applying for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage'Treatment and Disposal Systems)
n
,,�,/��``'�'`^-� �j ***NOT[CE***THIS AUTHORI7.ATION FUR WASTEWATER CONSTRUCTION
y��. ����! ,��r' /f��1�' / —��~�� � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
�
RESIDENTIAL SPECIFICATION:BUILDING TYPE �#BEllROOMS � #BATHS� ''7 #OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPE�CATION: FACILITY TYPE #PEOPLE #pEOPLFJSHIFf #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE ��� TYPE WATER SUPPLY �D DESIGN WASTEWATER FLOW(GPD)�(/v NEW SITE REPAIR SITE,��
, � , ,v � �� ` t��j �/ �
- SYSTEM SPECIFICATIONS: TANK SIZE ��` GAL. �MP TANK GAL. TRENCH WIDTH�� ROCK DEPTH N��'LINEAR FI'. ( Uv
OTHER
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT�RMIT�A`�OUT � , �
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FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT �
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;
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
*•THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE '
WTfH 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.
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�, PeqniEtee"s4 �` t � J j ,��. DAVIE COUNTY HEALTH DEPARTMENT
_.,N�e; - � �' `j +`" � d`4!ar:: F'�+C�o�'�c�� s w �ri- Environmental Health Section PROPERTY INFORMATION
_ �. �,i ( ;�,,. 1 f P.O. Box 848 .
�Directions to pmperty: � j ��`�� �� Mocksville,NC 27028 Subdivision Name:
Phone#: 336-751-8760
�• 1 .
"� �- ; ,:'�^j�C� �,ctit ��::��. ���- / '��sM1d 6/ � Section: Lot:
( /� �UTHORIZATION FOK
�'.�� (Itt�;�r�, it:+'.i� � , L!•,� ��-�f.t I'`L>C���' " VVASTEWATER °t[1�i✓_ �i�- <'r
r� Tax Office PIN:# - ` �> 1
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SYSTF,M CONSTRUCTION
AUTHORIZATION NO: a�����,�; A� l� �" RoadTlame�'l���� r�' '��` �.Ft ��i���t��'->
yr ..,. , +'Ge,� Zip: �
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**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. ` ; '
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Tr`eatment and Disposal Systems)
�i �
�.r! � ,:�r;l;:f��..,. _u ,�/ �j�***NOTICE***TH1S AUTHORI?,ATION FOR WASTEWATER CONSTRUCTION.
,rf��'��1� � ''�',��/r��y�'` '��- ' � T��w�� ` IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
�� �'
RESIDENTIAL SPECIFICATION:BUILDING TYPE � #BEUROOMS � #BATHS� '� #�OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
/
, �LOT SIZE ��� TYPE WATER SUPPLY �D DESIGN WASTEWATER FLOW(GPD)� NEW SITE REPAIR SITE r�',
' � SYSTEM SPECIFICATIONS: TANK SIZE lf x r�GAL.VPCIMP TANK���t'_GAL. TRENCH WIDTH��,ROCK DEPTH��7"�*' _INEAR Ff. !/�� '
OTHER
- �
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LA�OUT , �- �
:.-_ ��`�,. . ` �` .`y�r.� `M
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: �`
�
�;
- . �
`,"�
� .
, .
� .^" `
AUTHORIZATION N0. OPERATION PERMIT BY: DATE:
••THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE �•,.� .r�
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 SATISFACTOgILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 0?/02(Revised) ��'c " ,
, �