968 Liberty Church RdName:
w
t Directions to property:
AUTHORIZATION NO.
V,�g",rZAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P O Box 848
PROPERTY ORMATION
L'+V ►i;.
Mocksville, NC 27028 Subdivision Name: _
Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
002602 A Road Name: (u �'�
Lot:
**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 w4en applying ,for Building Pen -nits.
(In "compliance witttfArticl�l 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.
i
ENVIRONMENTAL HEALTH SPECIALIJTJ.' DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE I I (�ll�e # BEDROOMS ' # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY wA/rYDESIGN WASTEWATER FLOW (GPD) v NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �L LINEAR FT.��
OTHER == �i t `: j r 1 r / • 1 ! .al
I.�S�n.l t b� �[,rJ7c3�JL7 ,�`'l 1 `✓Li1 �►`-(l�._ I�JL l
REQUIRED SITE MODIFICATIONS/CONDITIONS: �
IMPROVEMENT PERMIT LAYOUT
( -j -
c n r: or;T
N`�,.j
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
AUTHORIZATION NO. 42W?- 4% OPERATIO
••THE ISSUANCE OF THIS OPERATION PERMIT
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECT
GUARANTEE THAT THE SYSTEM WILL FUNC I Wiv aH i iarAt, i vxu, i run tuv z
SYSTEM INSTALLED BY: SIhAJ t/U/J
DCHD 02102 (Revised)
yr i aura.
��� �AVIE COUNTY HEALTH DEPARTMENT
-JOEN�f
444- ,ilc - Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
- 2 11ir`ections to property: Mocksville, NC 27028 Subdivision Name:
11 i..Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
§ SYSTEM CONSTRUCTION
AUTHORIZATION`NO: ®2602 A Road Name.' Ur�% p:
**NOTEN* 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 l l 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 SPI CIALI§T DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS N# BATHS 1 # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
r4 rC
f LOT SIZE TYPE WATER SUPPLY .r 1010 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE /
SYSTEM SPECIFICATIONS: TANK SIZE - GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH / —� I LINEAR FT.
I
nTUPP ... /.. 1 f Lrf1l ..� t {• -
REQUIRED SITE MODIFICATIONS/CONDITIONS: '~-D
IMPROVEMENT PERMIT LAYOUT
r
... 4 _.11 .
�sF
j,
l
FLw''�i,...T `
l
�r
NtrJ tt
0
11 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. , I
OPERATION PERMIT SYSTEM INSTALLED BY: �T,04 `A" � 1� 01 /1..I
FP,0
L
CAQQoe r ,
itp X3U
r
AUTHORIZATION NO. 2U0 OPERATION PERMIT BY:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE TRAT7Bk S�
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREAT I\
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY
DCHD 07/02 (Revised)
a%-
� IV-
DATE:
BOVE BEEN INSTALLED IN COMPLIANCE
LL STE SHALL IN NO WAY BE TAKEN AS A
OF TIME.
i 1!' � `&.:': w LC Log r�° • ar� a4F.�'" �e y s r �, '�e � g a� �;..,�
� �� `� r :r� 1M e �. �e�' .�iu '. r � �*2r K '.. �d e�s�i� � "�'� `�iai�' � �,
���.."�,= ���V �',^�" .a i '� "�a5t �,���4�+ „ t� � w, ,. � -f a; °,� �..t�3 �-� w �
��.� � � �:+�`� k c�, s ��5,. '�k '..§ t t a k � �. w � y �'i'i.� zM� � ���rd 7��J=. �
. a�� .�"„'t� r . �.�,� .: � c fi'�.°. 5,.;: ,, � �, ���.. yi��, a'+� t�,,�"�'�'S t t� �" a *� .. �+j � '�y:'a a �°;, �
x,wE P � �4 is �`� �� ' �t t�� �' � >"� �r � �� ,:,rv4� j���� } r- r � � �y�g��
� � ��� � '4e�'��SK � � .�f . ��i� w� r �8���'�.�.a�' 2:��¢ ,t �43a `�'. +�a��r'�'�ati ����, � �; �A.� r �„i��✓s` .
r
�w�,,� r w�" ��,5 r ��. � �^a w«�" � ,s��`�'� �� � ��. ,�C�''� � �t� , i? ��+;�' k
..�, ���. .., �°�1i.� t����li+�� i ti.; �W�i ' �3�``+�y§;'� � a '�' .+w� 1i�s ,.a.- "r�`,'`�e�°'�� t �. "- a d.pf��,��,� ,'.^�.;
`� r.,.�., �, a � �,:,, a "'A� 4& amu,� .�� ,y� �; '` �-
1 f �r,;� ..� . � 5 �� �; . �"i'� s �,�r p°�y�..:. � 1,� � >,"c:"v��^ ,t�r.� '� '�yz '�-a' ' ++>r'��'�ti,'.:�� .^""��a?
�o� '��F�y`�. �aj,��,j�t 'b .� � S �i�Y[' �- �� _ . �"r �°"' ���� �� *..a&�'J�.-." ��a�°6'�`�"°4 � �r � d��y�,e p.,ar�����' *";�30
.
,-, z
� � �
=. 4 � � '�f .S� � � 'S. '. �: �� ,.� � ,�' �' .... �' y .a� ;... .. .��� ',�„p ��� � �: ii � ����Y
., ��`fi �., � , �i& Y� �. � �
s� 'ay,::+�` � � � �."<* a � W'` -��r� r �� �: '
�� � „�a' a �� � �_ '� F' a�g �� 2 '��° �I
'� +, ,.�. r., a i -r ,q�� � {..
. ��
'���` .. �4�,�.� �'�.i'i� "` '�: ' �' '� I
\ �� y����,� �iF� k � � �t a4��. '�.
� I
x.. � � I
� ` I
_ �
�� - 4
° '
< �
� � - ',, ' • _` ' i
3��
6Z40
,, , I
(V93 .
�E ".�, �
�, �
��. �
�x, I
o'
�, �
�,'. 3�2
. s
. . , ,�. . .. .
,., . . :� . . � � .„ a �
x �
,� �,� . .:� .
�:: ... .r �. . �.... - �_4'. ' � ' .
p n
u a�� ,�"�'.. il� �. s
.•'s 't ����`�
�' 4 4._5.w '' ��:A• �..
� E �(��,
�. �� /� !
I , ,,
'2�*�'''• '! . � ' 'A:.� i
4 � � � �
A`��� P ���� ` �I�
�f .�, �3 9� � ��:X �,� �
�z'
.s k a � �. , s, ,�-�s�
� �r�' � � ��
���al"' F a �� �` � *,il� ��'�
�' p��`��'��'^��° *. .��' �'' "�'a � � �
� � ..,7 :� e p' � h� � � .^� "+Mi.. � �°'� � �£ �I
�' � �
- d � x� ., r:�: t� �; 4�S x: t � . �' rr ''�:,� '
' �
.
�.
��qi��'s r�y� ' � i°��� ^ +� ''��
����' . ����, .` �
� >a� � a" �..
s
�x .,u �� ����
� Y "Y , a,�k'd 'e "w.,
5 - a� q*�Te�.. � .'+�' 'S�,
�'�' �:' F 5;�.,. �'
� aMt' �'-;, �..�'S: �r
,
. �
. . F ��
, , , .
� . . . . h � � �,�,
. ,
= � � �
;
� ,: .
_ .,
� � � � �� ;
_ . , �� +1C�� � �
g�. xt a '�� � �.� ��°� X c� ; ,, r
�� ..s td .� �� � ,�,�� ���:n* �i�.� '�- ,,�,
�
�+ � .. . ��. � } _ -
1 * � � �� � � �. ��� & . .
�r" A ..� " ,�' 'y������+ b *� ���� ��±k � z�� k"-''""k �� � �`'"� �`�'� � i���� `.1��k`� � � "q=� ,� e�� '�,
W
� � PT 3 � s'.,��v7�`;£ .� t ¢Pi�...�� 'f � / �
: : � 4, .' : ; .. '
z�
.. � ,� w . �, . � ' .. {. �':���
t. +`�' �5 ' �
T
,,e y,^�..�°'Y g�3� Y �' ,�` .S^ . v �,�'d*�a' ,� F� � �. �`� . : I
�' q
, r ,
,� r
. �+ �y . �� ��,,, .x ,''� 5. _ . r � �� � �. *� �""�' rwa,� � .
� ,a `�". t "5 '� ,. � � �a, t'. "' i;�'�'d
� �'«A ;�. ' � 7� a. ,r,� ,� < 4�.�`.�. � ..�ax'' y ���' :
,� .�� � �, s� �. a•��'�a 9 � ' �� ^4 �.a " �z
G r w y� �i�z'{a, r a i s v � �e� � sd
�k 4 � � �p � �M��� :� ����� r'��'�3�dy`,t�����
<
�v �`
� r " ."� <.� x �� .
,� F F y , � ��
�
k°J
i �;
s
� �..� .`-� #. �a
�,i:
,t.
.� r d.,,
+
�t
�.
A �» k� _
.�' ""� .���d, ,*
F.
+:�
.L
i � �
s
. '� n , x.R"" � �,�
-'
� .�
r _,
� � .
� _ .
� , ��
� , ,� .. �'"'_ .:
* � ."s T�,'� "p„�.,.. � �P`.:: �.� ..�,p �,,
�+ ,a j':`.� .t"�� .3'�1� . .. ,r
.
�..
F� �� ti. �.... k� fl
! �'i� f��` �.+�" �'�'� .
.��..��' �i,v '9� n �' , � �� � ���" �r i�"���`�' r�\���� �( ...� � � ��'�y� v ��"�'�"�' '�
. Jd .�`'-, *� *s �� � *i' az ' ; '
� ��{ � �$ s � ���7 �f i
h 3 � � ��,�, f � w r � `'�„� ,+�'' i � i
� *
�
b" j2. � � ������ � ,��°3� � I
,:� ��t, � �
u `��, �.
<
� 4
I B . .. ' . . �i
, ^w.'� P^r. . "`ti"t�
�
� � �� ,���' .�- • I
��� '/
;
�'�
t
, ,
� >, a � �': v
a
�. �y � �
�. � �r�-� `� � ' � ���� �
` �� 'k .�� � � �t a t u
� } ,�'' �' � r
A � �n!d� � �
3- E
, , �'� r �rt ..�.
r
I �. . . ._` � �r
F� ?" q
'Yh' 1., ��L .�%` C�S:` . # �k�
p�� xr'�!! i'� k 4 �� � ' � �M-�� � S .
I I
`^� � '�*" � � f �:, .� �°'' j , �� �.,� ,
, w � � ��� � �� � � � :� "�
. ar�ia.,�P ,� t�,� y �j �3 � +i `4C p'.. �'�"�"'°5 R�'
y,; �.„«e. .+4�
P f
��
�-;
� a; a
k�sF^- �# 8
f .'i !y1� ��+,,,��i ^v� �, x w f�� �' �4,., 5� �.-ap � ae� . �a'`r a� ��,` "` `i�, ��' 'E ����.... +��
� �;`�'a3.�` . ! �ta �^�� �. �°�°�'�k''g� '�� -M'. . a' � .a, �"3'.=.
��,,��
�Y '��'e ��, ��-� �'� ��u :�� ���� �r t�it � ��� �,1 ka� �� ��'Oy'' °����
s
g .#� 4pt��� �, k � - �� �� �s��,����`�u o''� *";'M-�" "'��Q��s '�,^�'.��
� �
y� '��. , � Y.: r ,:�" . ! o •au
6' P
°O.
V
f �� ��?� '$ f .^^€ '�a _ F` ,d" ^.�. .�'.. �� add�' ' ��
�" r�- . '� .7 .
�C S � '`�."`t
�A S f
� � _
,�, k .
.
.r��M l� ^+`i.'�.. � ` '� ��S :A y.,a S• N�"�'"r,. � .�:� �,�," 4> �. ` �.y^�.p .
"'YT.� ."� � A� .� ,�nv�� S`•`td^�1..
3`, � . _
I �£°� . . �:�s. ,.. �O.�
"',!�° "k�.
� �. .�� �.. �
� ,
� � �� t�:��"�'��,;f ��� ,� �' + �� ,,,
F, � � .� � �,�
��py
.
� � �
�„ �,x
S_�<
A R ,�-3. +�
7
���z Y #� t Y� � ,r , ',,#��p zW' � c'za.` e, �r�^ ��+`a'+�y �� �
a �� ���y�, ��� �� � :'� �t ��F ,� ��3+,y� '� '"�� { �} �� S A`
,t`fd�" s��as���� .m...x`,w. b"�.�`�"�',c�`�r�� r .: . �'�'9@�� �' �. � f� M�ps �#�f�� �` �+I�M`
,�g' � �
� � '� ,��;�"���, f �'• � s �'+ �� °� ,�� � x e- � �'��i.y .°�K�` ':�t� .
�u �°P�� �� .y�' ' a'
a
>�. �� �����C�c�S"��;.�'�. � � .S. °.;,� �;� r m�'�"' x ��''�. :;.������*� x ����� II
� #� , � ' t�� � �� F- �
�9� � �� ��'R������8> d' �2 ; , ? �,,� � A�t jl i� �`�;C
I �'1� � :�a � « 3 �' ' r �' ` •�r�� � � � � '�����x�`t"a����'` I
� .
,
��' ,y��,� w- ,� �,t�,� �s � `� ?� �.. _ ,��' '"r- ;r* a"a� o^s���'� �^a., ,�"s�- �t�-k�,'d*;� .� ;�
c p�� �_, ,� ' � *``�' � �p '�1+
�ix6. .v�a`CTta`. .. dw .:..��:,�.. " �e�s .. . . . .. �. 'a".J`.: "� .. . .,,... s.._ .
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
,. APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER hZ SS 13
ADDRESS SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 7 --
TYPE WATER SUPPLY C.eV,.Ltj SPECIFY PROBLEM OCCURRING ,9; L1 -)b
DATE REQUESTED 13 Lob INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
key3��l�ivva ij 113