214 Odell Myers Rd (3) a�2 ., .,j tl �'l.; i „)Yy t JLj A.`�'{'T'� r ,i:." t`,fi•M•i;,, :Z,:.i f j� >i( <l'.qv d .. _ . .l .'^.
AUTHORIZATION NO: ' 19 0 MDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee',.-- -^" P.O. Box 848
Name r'J�%/?f A i �.� �..� Subdivision Name:
• � •�-. ,. "Mocksville,NC 27028
Phone# 336-751-8760
Directions to property: !fly ;T- Section: Lot:
AUTHORIZATION FOR
WASTEWATER
E_.r� .G'I• i � f Tax Office PIN:# - -`
�! SYSTEM CONSTRUCTION f f
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 CountyBuilding Inspections,
Office when applying for Building Permits.
p p y' g Disposal(In cont liance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Dis sal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
' C IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTALA ALTH SPECIALIST DATE ISSUED
'" j>f+:r • � � e...-`"`a...- ;,`l(;r xer.=.� �,.;�*_�:.: y r.`.. ..�. - - �:'r1 t'•• ... r�' .�t ; . •ter-� .-. .-v ,-.� .,:
46VIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permitiee's.�-::.- .
14
Ma me Lt �`% _ 1V Subdivision Name:
r'
Directions to property: +" Section: Lot:
- t IMPROVEMENT
PERMIT Tax Office PIN:#
., f Road Name: f, Zip:
,*.*NOTE**This Improvement Permit DOES NOT authorize th 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)
x r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPD�Iy t1 #BEDROOMS _#BATHS'Z;><_#OCCUPANTS ` GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIA WASTE:Yes or No
LOT SIZE ' ` TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE�1
SYSTEM SPECIFICATIONS: TANK SIZI-a /'0 GAL. PUMP TANK GAL. TRENCH WIDT ROCK DEPTH fLINEAR FT.-?,,
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT.*pppROVED EFFLUENT FILTER* *RISER($) IF 6" . BELOW FINISHED GRADE*
,
1 !u 7e)
:K
"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(7MY--6xx'iW3 x
(336)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY:
Its
i�,
e r�lei
o .
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g
taw!(
$0 MP
AUTHORIZATION NO. `0 /`'i OPERATION PERMIT BY: ' — DATE: i O�
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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)
am x-.{r.�y ,' �- ? — T K:y%;.` � � w z Viµ.. ti �;�,, J�1�.w: ',�C�,�:.. 4 _ @.: Y +�,- ,`Y ti l'�_- •'t7 :t t.y^"".;ir, ",'r i .
0 7 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND-OPERATION PERMITS PROPERTY,INFORMATION
Permitfee's X
I
� j .
me: Subdivision Name:
}P�, i.. � r✓�R' f
`Directions to properly: Section: Lot:
1 IMPROVEMENT
. PERMIT Tax Office PIN:# -
Road Name: Zip:
**NOTE**This Improvement Permit DOES NOT authorize th construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYS M CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance f a building permit. 1
(In compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
t
r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
/ PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE�t`«J #BEDROOMS #BATHS'''" #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE t` TYPE WATER SUPPLY DESIGN '
�} � � WASTEWATER FLOW(GPD)�l •-t-✓ NEW SITE ' _ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZI (/' GAL. PUMP TANK GAL. TRENCH WIDTH. Y` ROCK DEF4HL2LINEAR FT.
1 OTHER `{ , f_: .�_ !1 r t _ l f i{ ��' r r"- y� =1�� /! ' %rl ! 1.'�%� '•
REQUIRED SITE MODIFICATIONS/CONDITIONS:---
;e
IMPROVEMENT PERMIT LAYOUT-XRPPR'DUED EFFLUENT FILTER* *RISER(S) IF 6" BELOW FINISHED GRRDE*
N.
"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 D kY OF INSTALLATION.TELEPHONE#IS
(336)751-8760
OPERATION PERMIT
( SYSTEM INSTALLED BY:
/ate
GQ r.
AUTHORIZATION NO.19o7,� OPERATION PERMIT BY: 2 V!2" DATE:�---- DATE: _,'j t�
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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)