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282 Milling Rd•Pcicces's DAVIE COUNTY HEALTH DEPARTMENT Na Environmental Health Section PROPERTY INFORM �-� P.O. Box 848 fN )OP Direcdo s to property:c� ,' ( Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 wit Section: Lot: 1-*(}/ttf 1r I ,- { j�� 'j? �a'. AUTHORIZATION FOR WASTEWATER Tax Office PIN:# 4. ,ctt) . i SYSTEM CONSTRUCTION - - 4, lit AUTHORIZATION NO: 0 0 2 G i tai 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 Perntits. This Fonn/Authorization Number should be presented to the bavie County Building Inspections Office when applying for Building Pen -nits. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ! ; r. `! ✓ r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS_ # BATHS_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No t COMMERCIAL SPECIFICATION: FACILITY TYPE Je # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �-3 W NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GU. TRENCH WIDTH V ROCK DEPTH_ LINEAR FT.�, OTHER ill .10-t1r 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. 11 OPERATION PERMIT SYSTEM INSTALLED BY: k!5' 5�6� AUTHORIZATION NO. C:7 9__CW OPERATION PERMIT BY: DATE: / 44 **THE 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 02102 (Revised) 1 �� 7 �t t,/ /0 J lJ UD r � ) 'Pe�tictee's' x, DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Sectt P.O. Box 848 n PROPERTY INFORMON ",, �Directions to Property;Mocksville, NC 27028 f, f,= Subdivision Name: M1,11 Phone #: 336-751-8760 - Section: Lot: j ` 1 1 AUTHORIZATION FOR 7 <, k: !. i;a +`;'r t` WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION AUTHORIZATION NO: 0 0 2 683 1 A 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 VALM FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED - RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS =_ # BATHS _ # OCCUPANTS GARBAGE DISPOSAL: Yes or No i COMMERCIAL SPECIFICATION: FACILITY TYPE _Wr— # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY t DESIGN WASTEWATER FLOW (GPD) '—� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK G�II. TRENCH WIDTH '- ROCK DEPTH Z `� LINEAR FT. OTHER t II 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. :1 OPERATION PERMIT SYSTEM INSTALLED BY: lI/1% `,`�/ X/,//61-- //61-- J AUTHORIZATION NO. r=VOPERATION PERMIT BY: DATE: f v **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 02/02 (Revised) 1 ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME�/��in z%Ciyt�n PHONE NUMBER ��✓��/� ADDRESS ��f� ;941n SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY -7 BEDROOMS '---? NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. ,/93 _,�� _,s r.L , ,�.�. R+�� . ;/o-��'-9� p"�'� ��_ � E C' ~H ALTH DEPART T � ��,.f , . �.. ,. . � , , �„ �1 ,�y� DAVI OUNTY E MEN w�A r �� IMPROVEMENTS PERMIT� ANfD CERTIFICATE OF COMPLETION � *NOTE:issued in Compliance With Article I I of G.S:Ghapter 130a , Sanitary�Sewage Systems� t' ` � '��,��' ' Pe1'n'1it NUn1b@1' � Name ��''��i;'�c"",��i�rf�� '�,�_G?�"�<�.� Date �'".�jc�;l"� _ , � �� ,r�f' y� �� . �� 3 �� I� Locati .:�. ,.y€.�` � c�l�t/- ��//�?' �..��r��'��`� ��+,/:�.�,.� �1�,' ;,��~";�".�` ./r, /�/.� , l' .�s7.�r�� .r.L��,_�t` �-�11�:�l',i�'1 �.t/ ;,�`.7`�... �" ' Subdivision Name 'j Lot No Sec. or Block No. �. 1 Lot: Size _ � f�'`�/�'i House Mobile' ome._�= Business �_ Speculation ! '. � k ' No. Bedrooms �_.No. Baths_�� ` Na in F mily�__ Garbage Disposal YES p NO ,0� Specifications for System: ,;,% i ; Auto Dish UVasher YES NO,�� ,� �� ,�'�,� ;' �~.��;,�' , , c:�°-, ' Auto Wash;Ma.hine �YES., NO < �s.. � �/"'� O �' ,,, � � `,- .. a ' , ,Type Water Suppiy � ' ' ` ��-� ��„r� , k ' *This,permit Void'if sewage system described below.j`s not.installed virithin 5 years from date of issue. °� ,This permit is subject to revocation if site plans or'�he intended use change. - , _ .. . , ��.., i h'. .�� , . . , . �" , . . �.. ��. i i, � .. . ..., '... . ,. , . �. . �� . � . .�. � : ..". . ,,. .:. . . . . .. ...: .`'� . . . . . :... � ':.�. , • ., -• .... . � , . . . .. ,t . . . . ��. , . .. . ,. '. fl , . � � � �� . . . . .� . . .:. . . � ...� . � . ' . - .. , � .... �... ,., . ,:�: . .,.; -� �a':�., :. � � � ' � ', . , , . .. .. . ,... , , , . . �� , . ,. , . ., . .. . . , . . . . . .. . � �; , ,. ; . ��. :� �, '' • . M��.^ � . ��. .. . , . :.;� , . . .. k».��.^�"+a+.�r" � � � . ' . "' . , . ' ' . � � ,-�' � � . . ... � ��. . . .. . ; . . , � . .�. . , . , � � ; � _� � w�...�.w....�.� , . , - � _, .. , . �. .„ �i � , : � . . . , ,.. . . . � � .. . . . . � . .� - , ' . „r�^ � � � - . 1� �. .: . . . . . . :. ;. ,� ,.��. ., . ., , '... ; _. . ��.: � , . ;:�� '�, �:� , . .� � . . .:�,. . , .. � �. ' ` � , �� . � , . � . . , �. . � � � . � ... i :. . �; .,, �,:' ' � a , Imp"rovements,permit by _—�� ' "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 day'of co,mpletion.'-Telephone`NumbPr.J04-634=5985. Final lnstallation Diagram: System installed by � � ��1 � �� ;. �,� � , . . . , � ". �r '�� ..q' . .. . .:....� ,.:�.. ��.�' . ,'.' , i.. , . :. .: . . . . . .. .. ' ... . . . .., �� .t -.. � . . r..n"""e"'...�"�""'i.'� . . .. ,. . . . ' �. � ..... . ,. Y+. . : ., � .� . .. .,..� ..'. '�.. �,�. ... . . .. . . . . ' � �,,, � „ , ` P. . a ,� . , ' � �, ..: � ,. , � , . .. . ',. , ..':- , .�: , ,� ..�; � � .. � � '- �1 . .. � . . : � .... . . � . .. a/�� _ _ � Certificate of Completion _� Date 1g � '�� "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth'in the above regulation, but shall in NO way be taken as a guarantee tF�at the system will function satisfactori,ly for any given period of time. I � ' I ♦_1. DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION PO Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: :(336)751-8760 September 11, 2006 Gerald Zickmund C/0 Kyle Swicegood Century 21 854 Valley Road Mocksville, NC 27028 Re: Sewage System Check 2182 Milling Road Dear Mr. Zickmund As requested, a representative from this office visited the aforementioned site on August 29, 2006. At the time of the visit, there was no visible indication of any type of sewage problem. Please be aware that the above statement is in no way intended, nor should be taken as a guarantee (extended or limited) that the sewage system will function properly for any given period of time. Please advise if we can be of further assistance. Sincerely, Robert B. Hall, h., R.S. Environmental Health Section