169 Pete Foster RdRIZATION NO. _ DAVIE COUNTY HEALTH DEPARTMENT (/
Environmental Health Section PROPERTY INFORMATION
Permittee's / P.O. Box 848
Name: t a'- /i' S '64iZ444 Mocksville, NC 27028 Subdivision Name:
/t Phone # 336-751-8760 ,
Directions to property: /_f� �C.j Section: Lot:
AUTHORIZATION FOR
-W 4 ./a, l' WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTION
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 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)
EWIRON
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name: Al
Directions to property:
f IMPROVEMENT
PERMIT
Subdivision Name:
Section: ' Lot:.
Tax Office PIN:# - -
Road N
Zip:
**NOTE** This Improvement Permit DOES NOT authorize the 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)
% ***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 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 � ` DESIGN WASTEWATER FLOW (GPD) yob %l% NEW SITE REPAIR SITEy
SYSTEM SPECIFICATIONS: TANK SIZF/ScC4 —GAL. PUMP TANK GAL. TRENCH WIDTH 1z ROCK DEPTH�,9 LINEAR Fr. -T .v
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUEsr'T FILTERK *RISER (S) IF 6' ° P'-71 01.4 FIr1ISNE1) GRADEf.
"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 (`NS�W- d.' H
(336)751-8760
OPERATION PERMIT
AUTHORIZATION NO. / 1d02 OPERATION PERMIT BY:
SYSTEM INSTALLED 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 05/96 (Revised)
4W
r
AP?U(ATION FOR SITE EVALUATION/IMPROVEMENT I'ERMilr & XIC
Davie County Health Department ("
Envilonmenta/Heaith Section
P.O.. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
***IMPORTANT***
INFORMATION IS
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
PROVIDED. the INFORMATION for instructions.
1. to be Billed
�to
/�Refer
�A/ ! l E J /�+
7B�ULLETIN
t ) ��"'�Confta�l� Person
Name
]�
_�pop/�/
W. 7' �
Mailing Address
t�,
y Home Phone j (p
L
LLQ
o
Business Phone
City/State/ZIP
�� b
2. Name on Permit/ATC
if Different than Above
Mailing Address
City/State/Zip
3. Application For:
❑ Site Evaluation
❑ Improvement Permit/ATC kL$Qth
a. system to Service:
❑ House ❑ Mobile
Home ❑ Business ❑ Industry ❑ Other
5. If Residence:
# People
# Bedrooms 2-1 # Bathrooms
U Dishwasher LI Garbage Disposal IV-Vlashing Machine LI Basement/Plumbing LI Basement/No Plumbing
6. If Business/Industry/Other: Specify type
# People # Sinks
# Commodes
# Showers
# Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City � h�Tell H Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
lefax Office PIN:
Property Address: Road NmC C�
City/Zip
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocicsville) to PROPERTY:
Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I au responsible for all charges incurred from
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE �[ — Z. �'O SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Da tc(s):
Client Notification Date:
EHS:
Revised DCHD (07/99)
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