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AtrTlp7.A�ION rlo: '� .Q DAVIE COUNTY HEALTH DEPARTMENT
aEnvironmental Health Section PROPERTY INFORMATION
Permittee'-s�//p� j� /, P.O.Box 848
r Name l /f� JSO/"� Mocksville',NC 27028 Subdivision Name:
Phone# 336-751-8760
Directions to property: f .�: �, �'tr Section: Lot:
AUTHORIZATION FOR ,►
WASTEWATER Tax Office PIN:A–V-40?-
SYSTEM CONSTRUCTION
2 Q Road Name:
**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.
(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`
.T7 � .,< `Y . � 'y y;if -•�<''� ''' +e. -z. .. _,;: :t, .t - •- ZO�L,g. VV .- ,-5-.:,
40 ' DAVIE COUNTY HEALTH DEPARTMENT
x.
TIVIPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name;_ =%� r`d/`j Subdivision Name: r �yad�
-� '`Directions to property: `.: �r % Section: ,+' Lot:
f. IMPROVEMENT
PERMITTax Office PIN.t. - -
4z dIdA310,1hRoad Name: Zip: /Me
**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 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
E VIRONMENTAL HEALTH SPECIALIST 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/J #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE 3 TYPE WATER SUPPLY ( D DESIGN WASTEWATER FLOW(GPD) NEW SITE !!!�: REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE OGD GAL. PUMP TANK GAL. TRENCH WIDTH �G, ROCK DEPTH�� LINEAR
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENTPERM LAYOUT
�1
r
"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 AY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT 1µ `b� SYSTEM INSTALLED BY:
� a
1X3 X y ,. /� �Al�
r
AUTHORIZATION NO. OPERATION PERMIT BY:�C.13/ D DATE.
"TETE 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 SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05196(Revised)
' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&A '
•� w� Davie County Health Department f2 t1(] R
Environmental Health Section D V L5 v 15
P.O. Box 848
Mocksville NC 27028 JUN — 8 +M
X
(7 3 6 j75�0
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED U LESSENVIROHEALTH
DAVI E E COOUU NTY
ALL THE REQUIRED INFORMATION IS PROVIDED.
Ac& AAAO-t�—ACS //1. Name to be Billed O,0 C-Q 3 .ZV7 C . Contact Person �C/� /-f7,O,:,: $D�
Mailing Address WI 116- 149(142—Al Z A1. Home Phone AQ A' 7S 77
City/State/Zip ,MQC4-'S t/lcf-4 , ,1,�.C �? 7U a S' Business Phone 33 9qi-7a7`I
2. Name on Permit/ATC if Different than Above
Mailing Address Cit /St t ip
�
P
3. Application For: Site Evaluation e Improvement Permit&ATC ❑ Both
4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms 3 # Bathrooms
ADishwasher 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 PXATk RTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: R,47— 004,qV 9/P CLy.S&O 1 WRITE DIRECTIONS(from
M ksville)TO PROPERTY:
Tax Office P,IN: # 5 7
Property Address: Road Name
AE�7- rV /-90 a
City/Zip ADmAxie. A/. C a-7o0
.of ' nc.Cv a.v /02U =
1
If in Subdivision provide information,as follows: 1
1 K
Name: MAi2 CH ClOD/o% 1
Section: Lot #:
1
This is to certify that the information provided is correct to the best of my knowledge. I understand that any pennit(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 ���il/ H. �C7C�T� to conduct all testing procedures
as necessary to determine thesitesuitability. �7
DATE 6 '� 6 7 SIGNATURE
Revised DCHD(06-96)
YOU MAY USE THE $ACK OF THIS )`ORAL FOR DRAWINC7 YOUR SITE PLAN. CAW, —?av?
aha ti SIDNEY F. HOOTS /
D.B. 175 Pg. 507
----- / i' N 33.47'22' E
231.61 � a: ��-•- // �'\ PGI
i
� , 3906. r O zh / ,/ '' •- L.c
-4. HOOTS so
ADj
75 Pg. 504 \ •°Za'
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09 7,
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504 6.71--J
NOTES
9- All. LOTS ARE SUBJECT N DAME COUNTY
HEALTH DEPARTMENT STANDARDS.
%� �— ,/ //��/ 1 I r 2. ROADS ARE TO BE