275 Madison Rd _ . _ . _ _ _
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Permittee's� �/� DAVIE COUNTY HEALTH DEPARTMENT �
� � ,_Na�e:ec.- • ������5'=` �i'%%�t'!`� � Environmental Health Section PROPERTY INFOR TION
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�recdons'to property��� .���'�,aG'�i � �F` Mocksville;NC 27028 Subdivision Name: .�� /
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_�_ Phone#:336-751-8760 _;
Section: Lot:
AUTHORIZATION FOR
WASTEWAT�R Tax Office PIN:# .
SYSTEM CONSTRUCTION � -
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< ALTTHORIZATION NO: d'w����� A � Road Narr6'�!Gr /�.$d/� Zi _
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**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Emironmental Health Section prior `
to issuance of any Building Pemuts:This Fom�/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Perrnits. � �
(ln compliance with Article l l of G.S.Chapter 130A;Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems)
� . . , „
j� � ''` ,*';� � —��. ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
��,..'`��t�f',�r°���.�'�:/'� ,�� � �),S'�J IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEAL7'H SPECIALIST DATE ISSUED •
RESIDENTIAL SPECIFICATION:BUILDING TYPE � #BEUROOMS�#BATHS�#OCCUPANTS / GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY 1'l'PE #PEOPLE #PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No '
\`LOT SIZE `TYPE WATER SUPPLY r�° t�� DESIGN WASTEWATER FLOW(GPD)�NEW SITE REPAIR SITE �
SYSTEM SPECIFiCATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH '
��/ROCK DEPTH J�LINEAR FT.� �
_ OTHER
'
' REQUIRED SITE MODIFICATIONS/CONDITIONS: '`
` IMPROVEMENT PERMIT LAYOUT -
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**CONTACT REP.�E`S�NT{TIVE OF T�IE DAVIE COUNTY HEAL AL INSPECTION OF THIS SYSTEM
gg 4•zn_o•�tn,A,y� nR 1;(�-'1:30 P.M:ON THE DA F I �.I� Tjf�I TEL PHONE#IS (336)751-8760. '
OPERATION PERMIT ,�/(J` C I
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AUTHORIZATION NO.C���OPERATION PERMIT BY: � DATE:
•'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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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Call rn,tl�Gti Bi• t�
, =: � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTIO w �'��'"� i� �{
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APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
'NAM � L��� ��' PHONE NUMBER �9� U�a��
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ADDRESS � � S G�CCC Srl/� i��•�'� SUBDIVISION NAME
d�l'd.�� �' a�Qo�� LOT#
DIRECTIONS TO SITE (� l 1��� ' i����L��/L ��• C I vuK �i. !'ha:I b�,l
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DATE SYSTEM INSTALLED ��-M?o•s NAME SYSTEM INSTALLED UNDER Ca,�-t S
TYPE FACILITY NI�K,�a�t— NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY G`�� SPECIFY PROBLEM OCCURRINGi:�s�Y��' � 1�at� S��
��,o �t � ��� �'��s-�
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DATE REQUESTED 3 l INFORMATION TAKEN BY (�r�
Thi�is to wrti(y that th�information provided is con�ct to tho best of my knowledys,and that und�rstand I sponsible}or all chargss(ncunsd(rom thia applicetion. �
SIGNATURE OF OWNER OR AUTHORIZED AGENT �
Rw.��93 n/J� 1/ � �' ` .�f4 /1 ��
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Ca�S f cr►�n� �r�- r , h
� DAVIE COUNTY HEALTH DEPARTMENT
��- � . (Septic Tank) Improvements Permit and.Certificate of Completion
"''' � (Ground Absorption Sewage�isposal System - G.S. Chap r 130-Article....13C��
OWNER OR G'ONTR�Z�`OR '. .. .'+,. ,►!!w.•.,. ►*,..c:.�' ��?�` � �DATE :!�'�l���iji -ERMIT
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LOCATION�, �'"� � �'�"e'` � r�w:s r – .Sc}. lr . ` 3 3 3
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S.R. N0.
SUBDIVISION NAME �S�/t/� LOT N0. -�-" SECTION OR BLOCK N0.
HOUSE MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS � N0. BATHROOMS edroom House 0 al. 6 S Ft
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GARBAGE DISPOSAL UNIT YES ❑ NO ['�"�� Three Be r c�o o'm Hous �,900 Ga l�.�900� F t�.
AUTO. DISHWASHER , YES � NO 0 Four Bedroom House 1000 GaT: 1200 Sq. Ft.
AUTO. WASH. MACHINE YES �NO ❑
SITE SUITABLE YES �N ❑ , �
S I ZE OF TANK o o ga l. � / �� ��� � ` ,ru�'�S' /� �D G:��' .��t�� Y`
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NITRIFICATION FIELD�_ (n � s . ft. '�1+��"` � r yA �`��' � ,� l't��'.S, � �"'� � ��f• ,�
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bEPTH OF STONE IN�LINES s �---`�`..�� /�� !�';1 ,�"�t �� �' r� rr.3'� ,�r�, ,,�,�e�:�r Q�"- +�; ,S � ,�` ,� .
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WATER SUPPLY: � Individual Public ❑ f �'; r„��,� ,t� r►l,� c•� a'�.� S� �+r�r�� . �
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IMPROVEMENTS PERMIT BY. . � INSTALLED BY y�1.6f C%"��%i�-ts._-,�. �-y�
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CERTIFICATE OF COMPLETI0�1 By „"`�,�` . , • _ Date ��`"�'�' ��'
(8/16/73) *Construction must com with all^ other applicable State and local regulations '
LOT AREA' „
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