190 N Pino Rd:.-.,:: "; rYr.: .; _;.:,� �-••. -: ,. t'F -.--:,.�, rnr s -..a r ..� . ,... .t �. .. ai _.. - - — --
I?AVIV COUNTY HEALTH DEPARTMENT
Name: I""7 "`�1� rT"l. i`"k. ='r-.! Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: / Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
t= Section: Lot:
AUTHORIZATION FOR
PJ ` fi rj, } 77) WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION (
AUTHORIZATION NO: 002624 A Road Name: r11c) N! I --)C ip: L C�
**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 applyjng for Building Permits.
(In compliance with Article 13 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
` tiM,r Z % t IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON trNT'ArUIM H S ti`CIA�`IS_ DATE 1 SLED
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 LfZ A4::LTER. SUPPLY1DESIGN WASTEWATER FLOW (GPD) ICO NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEIWD GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH (� LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: r
IMPROVEMENT PERMIT LAYOUT
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CTI
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14� oo '
A -n t;teted In 15A NCAC ISAA959(5)
accepted Sy=rthms Inay also be used
iw IE. - 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 Z\ SYSTEM INSTALLED BY: & i& n M &N M;'e I
,iib
foo°4't""
A ORIZATION N v OPERATION PERMIT BY: \ DATE: O •
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE A BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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t w1 RAVIF COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
V ' ' g, P.O. Boz 848
' '6irections to property: J Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
n t R. i C. t- ''' ,`, _ <; •-� i t,,} Section: Lot:
AUTHORIZATION FOR
1 ♦ (!; t^+J� WASTEWATER Tax Office PIN:# -
' SYSTEM CONSTRUCTION -
AUTHORIZATION NO: 002824 A Road Name: I -jL-zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issda6ce 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 1,1 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.
rENVIRON FNTAC.I48A TH SPECS IA(:1ST DATE 1 SU D
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
CikAlk=
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PF}OPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE "PE WATER SUPPLY kDESIGN WASTEWATER FLOW (GPD) C- NEW SITE REPAIR SITE
TY
SYSTEM SPECIFICATIONS: TANK SIZJQLK O GAL. PUMP TANK,.GAL.
GAL. TRENCH WIDTH ROCK DEPTH A c: LINEAR FT.
4 f1TI7FA �/ / IFYS } / a✓
REQUIRED SITE MODIFICATIONS/CONDITIONS: I—•��f– IL -L-, r 1M .:t � .�wi4 1Ca }� iz 141 �"'�'�1 •� t ", I rid. ( J
r , ---j . ?
IMPROVEMENT PERMIT LAYOUT
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ls<i
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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.
OPE TION PERMIT �, f a n
SYSTEM INSTALLED BY:
�t/
S
hoar
A �OTY OPERATION PERMIT B DATE: !� b
**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.
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� ' � VIE COUNTY HEALTH DEPARTMENT
�� ;_.— _ ,
,,� � � � � � ..� Environmental I-�ealth Section
;✓"� PO Box 848/210 Hospital Street �'
, ;� �
* Mocksville,: NC 27028 . �
. !:�i �� �,tp� 2 6 2007 : Phone (336)751'8760 . . '
;�i , L., �` 1V . '
1 i N E� � TE =WA TEWA'T�R `CERTIFICATION FOR DWELLING '
(C�c�a��i� :' ENT ❑ • REMODELINC���RECONNECTIOIV ❑
. , ,: , , . .,
Name, ..�: �' � � � ; 1 �' I N 3� � 'f" Phone 1Vumber: ,J �(;-� � �f �' Z� �� (Home)
... . , _, .�
.
Mailing Address: ,'•: ` `Y ' .. (Work).
`. ; :
'��s��"���. .I�:��� ��t��� . _
. -���
Detailed Directions'To?Sife.
I. Provertv Address ��,( l , � � .
—r-.. . .
. . _
, > ,
:
, , ,,; - .,
Please Fill;`In Tlie Follow�,ng Information About The Existing Dwellingc
:,. , ,� ; . : . .
Name System Installed Uncler �'' ����I ���fJ Type Of Dwellutg: . .
Date Systeni:�Installed(Month�Day/Yearj ���� • Num�bex Of Bedroonis Number Of People: .
.. ' r ,,,.Y' � -. ' . .
. ,.. . . . � •, ,. ..� � . ,, .
. Is The Dwelling Currently':Vacarit? Yes;O No ❑ If Yes, For. How Lorig1:
.'. Any Known°,Problems? Yes ❑ No �' If Yes, Explaui .
Please Fill�.�n The Following Infoxmation About The New Dwelling
.� `; �.� �i'� �% � '
,. ,�T Of Dwellin ' ' ; ...� ��rbe��B�c��S ' " •'Number Of Feople:
3'Pe: .:. � -
�.. • �. , •, , ` �
?C� Requested $y } � Date Requested I �� 1 � ��
( igna e) , .
, ;,1 ,.
, , �,,. :, r, F ff
: = br�Environmental Health O ice.'-:Use Only
, , ...
.,
: _.
� .
�: Approvec� Disapproved 0
- Couwnents. t ` _ - .
� + �
. f �
' Environmental Health Specialist �'' Date �
f : � ,.,._.,..�.::
'"`The sigmng`of this form�by.the Environmental.Healtti Staff is ui no way intended, nor should be taken as a
�;; guarantee(extended or limited)�that the;on=site. wastewater `system will�function.properly,for an�•given period of time.
. _ ,, . ,
. ;. . •
� . Paymenr Cash ❑ .Check 0 Money Order 0 # � , ' `Amount� $ Date:
Paid By 'Received By' �
�' ..
...
,.' Account # , . ... ,.. , .: ,'; � :Itivoice #: :.
Parmittee'9 r% �, ,- j COUNTY HEALTH DEPARTMENT
Name: Environmental `ll�+� Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: �� Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760 Section:
AUTHORIZATION FOR
WASTEWATER
T Of P
Lot:
SYSTEM CONSTRUCTION ax Tice IN.# - _-
AUTHORIZATION NO: 002824 A Road Name: lqO /� + Fu %aZip: on?
**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 apply for Building Permits.
(In compliarA�e V oTG.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.
DATE
.. I:. 1 �a.:. �. �.♦- W.. _�: •-amu" 1-h."�:t.S..Y.:vi, `n'i'w.�Y'F^ti.4 tl. ...G: '°�: o -i .. .. �iT ^i�-0��1 vY-' Y"'.''e•t� - _ ,.. - .'..i`-iw I /a i
PWrWttee' //'�% f -, �A_VI COUNTY HEALTH DEPARTMENT
Name:. 1. Environmental Health Section PROPERTY INFORMATION
P.O. Boz 848
M ` Directions to property: d `� �� Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
O''� YE
Section: Lot:
(% AUTHORIZATION FOR
1 Q iso O►J WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTION n -
AUTHORIZATION:NO: O O 2 8 2 4 A ' Road Name: �� . rJ f' 1-�t�Z
**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/Authorizaiion Number, should be presented to the Davie County Building Inspections
Office when apply- g for Building Permits.
,In 6 �`qr' p Systems, Section .1900 Sewage Treatment and Disposal Systems)
(In com�lian with-Artiel 1 of. G.S. Chapter. Wastewater S ste
-� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
1 Z 7T t7 ! IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON AKH S)"KCIA IS DATE JISUtD
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 �i " r""I•YPk ATER SUPPLY J&)Ej.j„.—DESIGN WASTEWATER FLOW (GPD)109 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE�O�� GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Z LINEAR FT._
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: I�z �w' '1"� V" �+E� `T�•' ^ I4 "'" i e id
IMPROVEMENT PERMIT LAYOUT
3a
�
>-�5
As stated in 15A NCAC 18A.i969(5
accepted Systems may also be use
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 STEM I TALL n
ED BY:
` oU5
t
21 �Z1
UTHORIZATION NO. OPERATION PERMIT BY: DATE: ✓�
"* E ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE AT THE SYSDESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE ATMENT AN ISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GU RANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY R ANY GIVEN PERIOD OF TIME.
ncrrnovozcxeviseal
4,14 R8gg0032 I azo
�z Davie County Health Depar '� C E
Environmental Health Sec
P.O. Box 84.8 APR 1 5
210 Hospital Street y
Courier # : 09-40-06 ENWRONMENTAL H
Mocksville, NC 27028 ECouNTr
Phone: (336) - 753 - 6780 Fxr: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
4
(Check One) Replacement Remodeling Reconnection
(�� �! rte- C7 E,�' l 14C ���-I
Name:- N ti's- L Phone Number , pp (Home)
Mailing Address: L � 1 IU L -1'L �. (Work)
At
Detailed Directions To Site:
Property Address: k'k L
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: IG ��� l��L. i`' Type Of Facility: '��CLfI •�I
i !
Date System Installed (Month/Date/Year): t � (1 � Number Of Bedrooms:__Number Of People: 3
Is The Facility Currently Vacant? Yes (.: ' If Yes, For How Long?
Any Known Problems? Yes CT�-)If Yes, Explain: t
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: A Number Of Bedroom400�1— Number of Peop4lA
Requested By: m Date Requested:
(Sign ture)
For Environmental Health Office Use Only
Approved sapproved
Comments: J';7G '-P 4 "Id �� P /Ji��= .^�i,2, "2 /7 /�di J.od7 C
I r0 <u I. y-1 I -
Environmental Health Specialist
Date: L/ 'off- -%
*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
Order #
,to
Paid By:4 6-fwjNn Received By: (21
Account #: SV 8L Invoice
InA; /4".1 i�. z'�' -i-v
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