262 Mason DrPerittee's_ f D V� COUNTY HEALTH DEPARTMENT �� CO. y d3
'Name: - ��--"` f tµl:-.1 Environmental Health Section PROPERTY INFORMATION
".�`
�� P.O. Box 848
Directions to property: 1- Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
17THORIZATION.FOR
WASTEWATER Tax Office PIN:# -
YSTF.M CONSTRUCTION ,
AUTHORIZATION NO: A Road Name: Myt4- J. -&—
**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 A 6clprl•} 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.
F,NVIROIQT�ENTAL.k►EALTH"- PECIALIST.,/ IDXTEhSSU6
RESIDENTIAL SPECIFICATION: BUILDING TYPE 1!—""'"'' # BEDROOMS # BATHS # OCCUPANTS ` GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPEECHIFICATION: FACILITY TYPE,,, t # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE 10 h` TYPE WATER SUPPLY �� : DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH %Z LINEAR FT.
OTHER 1 J) t o J i Pa)v o A
REQUIRED SITE MODIFICATIONS/CONDITIONS: T
(%
IMPROVEMENT PERMIT LAYOUT
5 yin{'
Ab
t *�
**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 THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT-
SYSTEM INSTALLED BY: _ � /\
� � .
fJoT I�JtSt
ToT/�rL
v\0 '
2?�
AUTHORIZATION NO. ` OPERATION PERMIT BY: A
*'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS B STALL D HOMPLIANCE
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 0202 (Revised)
:e A
1 U AVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
2003 PO Box 848/210 Hospital Street
�uN Mocksville, NC 27028
Phone: (336)751-8760
�IRJ^�tl�E41SAL �ZH
c°x: - ITE WASTEWATER CERTIFICATION FOR DWELLING
eck One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: i. (V, 6 r; z- 4 O C.`f Phone Number: 33 to ` TT 2 " a 86 0 (Home)
Mailing Address: 2 (. 2- .�%� A5 -x . ) a • -v f4rz- 939 -a2L-OSb2- (Work)
Detailed Directions To Site: N intJ
au VznA Lr2— 1.s -� c� ►2,� VC i n AJ ,Inn 5cru J)Vly� ��) o r►� i t. o �u M .� scN
::aLr2fj ig►r-NT 6A) OAof£wc'P`i wIjH C YW4 mrTAL Buu.Dpmjti (fir 'Dotw-e PASr LO(' C,443)�?)
Property Address: ':2- I%%.,t-so r- D A— J-0 -r 3 2
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: � 1 eH A AV uN c a N Type Of Dwelling: My m L L 14o n i,
Date System Installed(Month/Day/Year):16 -161t, r Number Of Bedrooms: 3 Number Of People:_
Is The Dwelling Currently Vacant? YesX No ❑ If
Any Known Problems? Yes ❑ No;K If Yes, Explau
d— h 'D ► (l...-. L
, F,or How Long? /ytog rLt 1'tonui- V -C n V -, Q 3 `?" 44 O
L.r o
Please Fill In The Following Information About The New Dwelling:
Type Of
Requested By:,
(Signature)
umber Of Bedrooms: 3 Number Of People: 1
For Environmental Health Office Use Only
-:.- tr a---)- a9 -A
Approved 0 Disapproved 0
Environmental Health
Requested:
IP 11�&vr (.0111
mo /vr""
*The signing of this form by the Environmental Health Staff ism no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash 0
Chet oney Order ❑ #6-17 7 Amount: $ "�-O Date:
Paid By: J - Received By: -
Account #: Invoice #:
Fx'• 11,y " { 9
f_ �.� '5I �.,,.: lr'ft. J4%711 I
MAVIE (COUNTV HEAL''TH 'TWDEPARTMENT { '
IMPRO EMENTSPERMITAND#CERTIFICATEOF COMPLETIONtr r�, ,`
h.
t x `L. c s r �i71iw Z,tR,QC? :'. . f ,r
I =.''NOTE �Issuedin Compliance With Article I I of G.S LChapter�130a 7
fanit ry Sewage Systems : 9 <Perimft NumtieNa
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r � �� ���,��3 ` t `�
�� '1J +,'nom':pe.SV �\1•P� MN .Ce��C Yf: w"Ca �.S i -3 ti
Locatiom
s k t /1 w�;f I r! �,R ♦ a} �, ! ,. i 5 � t J .�'i4 r �w .w+ "y d �,
7,7-t
S.
:XSubdivision'.Name Lot No: Sec. or=Block'N- Y`
� ar r,', ieakta+313 by CiX 1. 'y r,.� r�.� a.�y {v!J«:�,i: f.�'y�. i'r'i *` � wr �. ii ,�ii i:±�f:' . .y..rao- a.+�w+K.,.»^w rw.*..a•..::,>y "-,wi.' +.w...»,«-..... � M
�L`ottvSize "L' ;House. Mobile Home Bu7777777.,
siness Speculation=
} .,r)Cd. �- T 171
a �, No Bedrooms No. Baths, No„ rnkFamily
Garb ageDtsposal 1y J t AYESQO c4' Cin t✓v€ it�S �ci�ya!r ns or_"�}ste+�" r�' "fit •r., `y s fir,
Auto Dish Washer � v ,-+ YES ❑ ` NO `� f ' '` 9;�,z,srp-b ,4
,,. +t „ �i' V yrT .r 4t~=1 v yLQ n i�..: `' "+ 1 �K"`�
Auto Wash Ma hlne YES NO i4 o x d �( i I,
i"��•F'�2 sic r'�
Type Water SupPIY.,
*This permit Void ,,sewage system„described belgw is not"installed wi thin 5"years jr
date of issue
Tghis permitiis�subict_to revocat on..if site'plans;,o tf�e i*ritetnfded usechaAr99e; ;
tit r m ci ri, e( ��
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ry .. � ♦ � 1t]� 21 3. U it `r+,1� L. { 1 � .1. 4, w L ,i: /t�� .a
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y L C 1 + wa Au •r'A .+- a3' fP 4,r. I 1 -+i ..iJ 4y . £ w . �I
wit:*� Improvementsipermittby,_ ,
sry �,''M +�{'y'$ "f 't/d �: t'°+i rr1n♦A.,
w'The,signipg•;of this�certifi¢ate shall'indicate that,the system. described;` above has,. been; installed in'=mpliance with,.`.
the standards set forth`in he above`regulation, but shall'in NO, way be taken as a guaranteethat the system will function'”
satisfactorii for an ive eriod of time.