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�UT1TRIZATION.NO: , -j9,8 2 DAVIE C ' UNTY HEALTH DEPARTMENT
trivironmental Health Section PROPERTY INFORMATION
Permittee's . " f �' P.O.Box 848
Name: Mocksville,'NC 27028 Subdivision Name: VZZid'.—j4:)Qd5
>, ,ff,jj / Phone#`336-751-8760
Directions to property: '�"t''ri Section: Lot:"
AUTHORIZATION FOR - J
WASTEWATER Tax OfficePIN:#�-
SYSTEM CONSTRUCTION
.Road Name: . .
r �d
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Perrruts.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
In compliance with Article I I of G.S..Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
`✓ ,J ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION.
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
`lbw+► M,A �, � ' .', �
0 DAVIE COUNTY HEALTH DEPARTMENT.
IMPROVEMENT AND OPERATION PERMITS 'PROPERTY INFORMATION
Name: �✓l ' , f . Subdivision Name:
15iiections to property: , �r Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN _. :..
Road Name �� e
/ 6//c // C p:--R -
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An,
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained in this Department prior to the
construction/installation of a system or the issuance of a building permit.
i
(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 SPE IALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE:. .
.'INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #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 DESIGN WASTEWATER FLOW(GPD) NEW SITEy REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �'LINEAR Fr. rw
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT tAPPROVED EFFL DENT FILTE * tRISER(S) IF stt BEIM FIRISHED
GRADE*
_ SdQ� /I
v�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPAR)ZJENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INS L TION.TELEPHONE#IS (336)751=8760: ;
OPERATION PERMIT
SYSTEM INSTALLED Y:
AUTHORIZATION NO. / OPERATION PERMIT BY:�A Y GwN DATE: O
**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.
DCHD 05/'96(Revised)
r ' ,
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& R r`R a
Davie County Health Department D L5 L5
^� Environmental Health Section
P.O. Box 848 JUN _ 8 199
Mocksville NC 27028
ENVIRONMENTAL HEALTH
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED U1 DAVIE COUNTY
ALL THE REQUIRED INFORMATION IS PROVIDED.
1.
1. Name to be Billed / ,� �1(�/-/28 0-4)6EJS%.�C . Contact Person Ael,
Mailing Address o7a S [ 0IN6- /440!-=A/ ZAL. Home Phone ' 79 77
City/State/Zip ,IYIOG�5 t/lc.e,E . Al.C 2 70 02 Business Phone 334 f9g9-7a.7 7
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms 3 # Bathrooms
AI Dishwasher X Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PXAiVMTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: R,47- Pe,4 / /{�C(_USc� 1 WRITE DIRECTIONS(from
Tax O . A09C
sville)TO PROPERTY:
ffice PIN: # � 7 � g - -76- - 15-8 d�
1 /S8 7v 80/
Property Address: Road NameODCF�3
1 Ie1- /-7o A
ADt/A�_ 'd/. C a-7o 0 '
City/Zip �
1 7&r,Z V 0,V
If in Subdivision provide information,as follows:
1 K
Name: 1".4,Q C11 W06 Q, 1
1 / 70 X'2Cd
Section: Lot #: z Z 1
11,U DAY �r.
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)issued hereafter
are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is
falsified or changed.I,also,understand that I am responsible for all charges incurred from this application. 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 L/��il/ / . OC)T-S to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 es
ro — 7 & SIGNATURE
Revised DCHD(06-96)
YOU MAY USE THE BACK Of THIS FORM FOR DRAWING YOUR SITE PLAN. C/��✓vr '
SIDNEY F. HOOTS
D.B. 175 Pg. 507
a
------ J/ /� N 33.47'22' E '231.61
!
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ro ( WT #8
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75 Pg. 504 �� "' / \ .02s' �� / LOT,'#7''
11
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LO �/� ( r \` ��` — �' / \ ' / ; �\ —_}fAL E�9E�ENi i i /! /�I[0 �'' Il cu ire I
LOT 2 `LOT Al
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/ LOT 17 --T350 1— I
OT
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(PUBLIC) 1
�EItSE]IEPIT(7YP.) _ J ' '/ ! / '!'/ ,//'�' ' / / // `\ , ✓t ,; 11Q3 ———`——130\-- 1
'LOT
I��1/•L/OT1 j % r/ f it i I i /.' = = r/ / LOT.\#9 I I
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LOT 1 I n / i 0 \ � �I
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< //' ElOT 2 �� ' /'� /' /I I I l i r \` \ (\ �� --� '130 , I1
ci !� I 1 ' ' \ \; ��\ 140
140 / I 1
TS 504 , � .71-_�
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NOTES
61/�
�
1. ALL LOTS ARE SUBJECT' TU DAVIE
COUNTY
HEALTH DEPARTMENT STANDARDS
-
• ROADS ARE TO BE BUILT T 7