1733 Peoples Creek RdPermittee'°_� - ---1—'—"" DAVIE COUNTY HEALTH DEPARTMENT
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Name: er" _j %' a`' Environmental Health Section
l l 7 P.O. Box 848
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PROPERTY INFORMATION
Directions to roperty: �' "' Mocksville, NC 27028 Subdivision Name:
i Phone #: 336-751-8760
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AUTHORIZATION NO: A
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
Section:
Lot:
Tax OfficePIN��z�
Road Nametjt;;3`_ ley' Zip:�r`tL t1 (�
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
AL'HEALTH SPECIALIST
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
DATE ISSUED
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 TYPE WATER SUPPLY 15ESIGN WASTEWATER FLOW (GPD) N4e�D NEW SITE < i^ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 0` 0 GAL. PUMP TANK GAL. TRENCH WIDTH c. ..a ROCK DEPTH LINEAR FT.._5D_
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS
IMPROVEMENT PERMIT LAYOUT
I—A
"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:
. St
C4 tie
AUTHORIZATION N OPERATION 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 07/02 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
' APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME �� e S PHONE NUMBER
Jl
ADDRESS �o (�S _ SUBDIVISION NAME
J e-- LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER 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. 1/93
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Account #: 989900611
Billed To: Jeff Jones
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O..Boz 818/210 Hospital Street
' Mock.ville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Reference Name: .Jeff Jones '7 3 `1 z41° I
Proposed Facility: Residence
Tax PIN/EH #: 5880-30-8385
Subdivision Info:
3a�3
Location/Address: Peoples Creek Road -27006
Property Size: 375 x 402
ATC Number: 2084
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHOR17ATION 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERIAIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
W,1.6 l C' VVA,.i r 2l l Y j EUVI l,VPl l i(ACTOR Iii UST SEE If in—S FERrtYl i ll`I,SYA' J -1,U G S Y; fh—Ni.
Residential Specification: Building Type WatzE #People #Bedrooms #Baths �.
Dishwasher: Garbage Disposal: [ Washing Machine: Basement w/Plumbing: Basement/No Plumbing: 13
Commercial Specification: Facility Type #People #People/Shift ##Seea�ts Industrial Waste:
Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: NewX Repair
System Specifications: Tank Size%GAL. Pump ank /OOOGAL. Trench Width �` Rock Depth Q 'Linear Ft. -
Other:
Required Site Modifications/Conditions: f��/
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 K BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental He Ili Specialist's Signature: % �' Date:—��-
DCHD 05/99 ( e ) A
6 lY C -A U—ML—t c 0 A
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DAVIE COUNTY HEALTH DEPARTMENT '
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #:
989900611
Tax PIN/EH #: 5880-30-8385
Billed To:
Jeff Jones
Subdivision Info:
Reference Name:
Jeff Jones
Location/Address: Peoples Creek Road -27006
Proposed Facility:
Residence
Property Size: 375 x 402
ATC Number: 2084
AUTHORIZA i ION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
wen!th Qertion, prior to issuance of any building nermit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article I 1 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
Septic System Installed By:
Environmental Health Specialist's Signature :
DCHD 05/99 (Revised)
Date: