213 Mullins RdPermitte4's,� DAVIE COUNTY HEALTH DEPARTMENT
Name: f�rl . f' ` !''/ :� : r �/ Environmental Health Section
K} •.r51 P.O. Box 848
Directions to property;�" � %/" i t'` ('
AUTHORIZATION NO: 002565 A
Mocksville, NC 27028
Phone #: 336-751-8760
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
9SPRO1Qe r- C93-
PROPERTY
PERTY INFORMATION
Subdivision Name:
Section:
Tax Office PIN:#
Road Name:
Lot:
Zip:
**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)
�,�' 1 . [7'`,� { ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
I'ii e 1 0.' a'l�i �'�'"s IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE __Zjjj# BEDROOMS—,? # BATHS 9 # OCCUPANTS ,� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
Y I^
LOT SIZE JYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 6)NEW SITE REPAIR SITE r
l
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. lei'
H 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 �i� I An X!
SYSTEM INSTALLED BY: � vl ,
AUTHORIZATION NO. �%�c/ C/-� ppgRATION PERMIT BY: �// DATE: L /a
**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 02/02 (Revised) Ke�:�,1. Y,
" �� X14^ > T S'S
Permittees f f DAVIE COUNTY HEALTH DEPARTMENT
?rame`: `' . ` if ��' f / f '• Environmental Health Section PROPERTY INFORMATION
a'.
�x;1,•,.;; P.O. Box 848
Directions to property! 'N IL Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION NO: w 0 0 2 5 G 5 A Road Name: Zip:
**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 Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen -nits.
(In compliance with Article I I 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
RESIDENTIAL SPECIFICATION: BUILDING TYPE f# BEDROOMS ? # BATHS __9 # OCCUPANTS GARBAGE DISPOSAL:.Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZ&-- f " . �i ` YPE WATER SUPPLY ( O DESIGN WASTEWATER FLOW (GPD) ` f L NEW SITE REPAIR SITE
a ! N
j
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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.
OPERATION PERMIT
SYSTEM INSTALLED BY:
Cz
C�
o -a ctiAM6��
AUTHORIZATION NO. 0_2���RATION PERMIT BY: � / DATE:
"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 0=2 (Revised) /� t -. , 0 * t L S S
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: I /", 'C k C P A d, J e_ � e- LA 5 Phone Number: 9 9 3 r a?;2 (Home)
Mailing Address: 62,23 /110'Lo f QJ SRR, 77 (Work)
Detailed Directions To Site: / C.
on (`i<Inr� �'l., �' S P(:04• r I1O�^1 C / t F `i[IP C?"
Property Address: -715 Rd iyC P 7D z B
Please Fill In The Following Information About The Existing Dwelling:
J`
Name System Installed Under: / ' � l C `�-� 14"- k `Le� ! Type Of Dwelling: 'So
Date System Installed(Month/Day/Year): Number Of Bedrooms: '2— Number Of People: 3
Is The Dwelling Currently Vacant? Yes ❑ No @4 ' If Yes, For How Long?,
Any Known Problems? Yes ❑ No 9"' If Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: / Number Of Bedrooms: 3 Number Of People: 3
Requested By: dam` t"t - � ��r�4 — Date Requested:
(Signature)
For Environmental Health Office Use Only
t
Approved Disapproved ❑
Comments:
%, /
Environmental Health Svecialist "Y// _ _ _ Date��.- . S
'"The signing of this form by the Environmental Health Staff is in 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 ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By: C Received By:
Account #: j�1 Invoice #:—
a
AX714ORIZATION NO: 019 DAVIE COUNTY HEALTH DEPARTMENT
1, , I Environmental Health Section PROPERTY INFORMATION
Permittee 's P.O. Box 848
Name:�T�ta',7�: ti�rr�3� Mocksville, NC 27028 Subdivision Name:
� Phone # 336-751-8760
Directions to property: lift"'I AUTHORIZATION FOR Section. Lot:
WASTEWATER Tax Office PIN:# -7 -/-
SYSTEM CONSTRUCTION
1 �� ��
Road Name:`! 151 Zip: ` .�
**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 bavie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
i/ , ` /�. {�� ;�' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS �_ # BATHS —!2L # OCCUPANTS _-9 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE4LOW TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) - " - NEW SITE_ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEAM GAL. PUMP TANK GAL. TRENCH WIDTH ?l-• ROCK DEPTHZ.2-L LINEAR FT. OeD
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
F
"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: _
i
AUTHORIZATION NO. OPERATION PERMIT BY:� DATE: _/ I
"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 05/96 (Revised)