241 Peoples Creek RdPeimittee'sd DAVIE COUNTY HEALTH , .
.. DEPARTMENT
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Name: �2 �a .° �' Fd ,,►�.>� Environmental Health Section PROPERTY INFORMATION
= P.O. Box 848 z -3
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P P Y Mocksville NC 27028 Subdivision Name:
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Phone #: 336-751-8760
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Section:
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AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO:
4:%A
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 I 1 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
• a �,?f .t:r;,+� Af� +'"✓ ;;3, //} �✓ /'� �` (^� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HIHALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE/ # BEDROOMS a 3 # BATHS 42. # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
41011-1
LOT SIZE TYPE WATER SUPPLY �C DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE'
SYSTEM SPECIFICATIONS: TANK SIZE �w GAL. PUMP TANK GAL. TRENCH WIDTH %- /,'Y ROCK DEPTH �" LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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44-e,c-l' -7—Ae�3
"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 INST
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AUTHORIZATION NOd OPERATION PERMIT BY: CI �l �/- 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 HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
�rS nitary Sewage Systems Permit Number
Name �'/,r'�F% , j. N O 7 2 8 2 ,,
Location '`— �/,�„ r ,
Subdivision Name Lot No. Sec. or Block No.
Lot Size House / Mobile Home _ Business -- Speculation
No. Bedrooms .No. Baths —No. in Family —
Garbage Disposal YES ❑ NO-~ Specific tions for S tem:
Auto Dish Washer YES ❑ NO��,.�,.
Auto Wash Ma shine YES NO ❑ ''
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements 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 completion. Telephone Number 704-634-5985.
Final Installation Diagram:
System Installed
Certificate of Completion
'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 that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
► DECO-
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
Number: t_�p 6- 969- ?W9p (Home)
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: Type Of Dwelling: 5
Date System Installed(Month/Day/Year): Number Of Bedrooms: �-- Number Of People:
Is The Dwelling Currently Vacant? Yes ❑ No 0---T-Yes, For How Long?
Any Known Problems? Yes ❑ No L_—ff-Y_e`s, Explain:
Please Fill In The Following Information About The New Dwelling: D 0 h /-C L'.;'. --
Type Of Dwelling:,MA.Ci' Number Of Bedrooms: 2 Number Of People: .1-3
Requested By
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Requested:c�-
Environmental Health Specialist �O��y�' Date
'"The signing of this form by the Env��nmental Health Staff is in no way intended, nor should be taken as a
Ruarantee(extended or limited) tha£the on-site wastewater system will function Properly for anv Riven period of time.
Payment: Cash ❑ Check Money Order ❑ #_ s E-0 2 Amount: $.,,p ea -40
Paid By: Received By:
Account #: Invoice #: __:�S3 2
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