330 Pete Foster RdV J
Permittee'sDAVIE COUNTY HEALTH DEPARTMENT
Name: i'' `L >' Environmental Health Section PROPERTY INFORMATION
or
P.O. Box 848
Directions to property:-- y Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
i Section:
AUTHORIZATION NO: 002578 A
Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
Road Name:
-1'-C� 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)
r ,
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE +— � BEPROOMS,4-7� # 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 .SESIGN WASTEWATER FLOW (GPDY f.� NEW SITE REPAIR SITE
AN'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �--% LINEAR FT. ,
OTHER
acciz:w As stated in 15A NCAC 18A.1959(5)
REQUIRED SITE MODIFICATIONS/CONDITIONS: VoCepted Systems m-lY ,iiso he nr.
IMPROVEMENT PERMIT LAYOUT""
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11 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. 1
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION N0� OPERATION PERMIT BY
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DATE:^C
"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 07/02 (Revised) _ Q-�— —'� -- — 7
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Pernitee'sr _ DAVIE COUNTY HEALTH DEPARTMENT
Name: E . / P (? Environmental Health Section PROPERTY INFORMATION
'''~ P.O. Box 848 /J
Directions to property: ' ' Mocksville, NC 27028 Subdivision Natne:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
Rnart NJa • ��� r % : f" � lin• v _:
AUTHORIZATION NO: 0025780 A
**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)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE _ ,# BEDROOMS�� # BATHS 143 # OCCUPANTS --*GARBAGE DISPOSAL: Yes or No
r
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY .DESIGN WASTEWATER FLOW (GPD)', -` NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH - r! ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT -
i
�f
11 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.
I OPERATION PERMIT
SYSTEM INSTALLED BY:
0-2
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I
j
AUTHORIZATION NO. ! ? APERATION 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.
MID 07/02 (Revised) tN
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Pemtillee s% [/,, DAVIF.!COUNTY+H EA LTHDEPARTMENT
//fj(1 /e Emvonmental Health Section PROPERTY INFORMATION
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Directions to progeny:—�1-7D A.villc. NQ 27028 SiibdivixionNamc:
7✓/b, / j ✓ �� _ �.�,/ Phone.#:'336-751=8760 Suclioni Loc
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IYdSTEN'At
S R Tax'.Olfce PIN:k
- - \'S"1'ISM1LGONSTR1ICPION - -
AUTHORIZATIONNO: 002578 'A., 1, lif Rdud Name: Zia:
t, Boilding P nml. Thi, FoOnWahu67aflon iNulnher,hould bL pre,enwd Iu dle Duvic:C..ailvEl.ildin@
31vn+ for BaddwePennit,.;' y
I IIoLG S:Chapler130A; WaI wateiSyacnn. Secdow.g91X) ScW age Treamlonl arm Dklxj sal Sy,i,cm,el
RESIDENTIAL SPECIFICATION: BUILDING.TYPE #BEDROOMS jn BATHS�,Y 0OCCUPANTs -S—'GARBAGE DISPOSAL Yes or No
COMMERCIAL'SPECIFICATION: FACILITY TYPE_ #PEOPLE_ #PEOPLEISHIFT #SEATS_ INDUSTRIAL WASTE:,Yes or No
TIG li //�
LOT,SIZE TYPE WATER SUPPLY,- .DESIGN WASTEWATER iFLOW IGPDISOv NF.W,SITF. REPAIR SITE %—
SYSTEM SPECIFICATIONS TANK SIZE 'GAL. PUMPTAN K_GAL.' TRENCH WIDTH: ROCK DEPTH ./ LINEARF.,F-r/
_.. .
IMPROVEMENT PERMITLAYOUT ( �
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FOR FINAL INSPECTION OPTHIS SYSTEM PLEASE CALL BETWEEN S:30. 9:30 AIM. ON THE DAY OF INSTALLATION: TEL[PHONE p IS (336) 81:8160.
OPERATION PERMIT
SYSTEM INSTALLED BY:
,� 7
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'AUTHORIZATION NO /J '/ OPERATION PERMITBY: rt ' -"✓ %DATE-
•'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED
WITH ARTICLE I I;OF G S: CHAPTER 130Ar SECTION :1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS"; BUT SHALL
IN COMPLIANCE
IN NOWAY -BETAKEN AS'A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILYFOR ANY, GIVEN PERIOD OF TIME.,
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XPi«�/' f / DAME COUNTY HEALTH DF.PA RTb1ENT
Name if. �r%'='� �/ " /Qn10 .P 'Favironmenial Health Section
PROPERTY INI'ORNIATION
P.OA3o\ 848
NDiredioris to property: _S_ -C u - l d AIock>eille. N C'_7028 Subdoi.s..ui Nome:
Phone #:.336-751-8760 Section Lot
A u'rHIIRIZATIONFON
WASTENVATF:R. "I'ac-0Ilice PIN:p -
SYS'rF,M CONSTRUC'1Tt IN
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AUTHORIZATIONNO. 00.2578 A Road N.me: r�T''. �%�� Lip: � 1
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""NOTE""'I?iis Aulholiiiition fur Wa.Icwmer SvNem Cnmlruciiun,\IUST.OG ISSU1°U by the On, County. 1:nviron nenlal'Healff, Section prior
to issuance Mum "Building Peri : This FomUAmho_rivulion NumMr.xhould In pn',�eiicd to the bueic County, l3uilJing Inspeeliunc
Office,when'nplilying to, Hmlding Pennits.
(In compliance With Anicle I I of GS, Chapter 130A. WILSICW31el.S}' tents. Section .I(XH1 Scwuec Treatment and Dispo.al Systema
ENVIRONMENTAL HEA:FH SPECIALIST DATH ISSUED pp
RESIDENTIAL SPECIFICATION: BUILDINGTYPE_VIa BEOROOMS,a BATHSa OCCUPANTS GARBAGE DISPOSAL: Yes or No
.a
COMMERCIAL SPECIFICATION:.FACII:ITY TYPE ,aPEOPLE / nPEOPLEISHIFT_ NSEATS_INDUSTRIAC WASTE: Yes or No
LOTSIZE TYPE WATER 'SUPPLY. DESIGN WASTEWATER FLOW (GPD)�3Uv'NEW, SITH REPAIR SITE
L I'V I
SYSTEM SPECIFICATIONS: .TANK SIZE GAL. PUMPTANK GAL. TRENCH WIDTH-Z<f� ROCKDEFIH-/,�2LINEARFT.L-a/
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERM IT LAYOUT
.Ik �
7' iP• . I
;v I .
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J 1 1
17t I
FOR FINAL INSPECTION OFTHIS SYSTEM PLEASE CALL BETWEEN 890- 9'.30 A.N. ON THE DAY OF INSTALLATION; TELEPHONE. IS (336) 751.8760:
OPERATION PERMIT SYSTEM INSTALLED BY: �! / QI�I / �/ C // a/7AJ
1-5
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ZrAUTHORIZATION NO: � /"OPERATION PERMIT BY: DATE: '9
--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 NOWAY BE TAKEN ASA
GUARANTEE THATTHE SYSTEM WILL FUNCTION SATISFACrORILY:_FOR ANY GIVEN PERIOD OF TIME.
..W.O2lNeviW1 \ - Coil. - I! /3.S -'I�.✓ �F.1��%
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �S
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME6? 5PHONE NUMBER��
ADDRESS cN l ��' �S SUBDIVISION NAME
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 REQUESTEINFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that
I understand I am responsibleforall charges incurred from this application.
V SIGNATURE OF OWNER OR AUTHORIZED AGENT X714u--- 4
Rev. 1193