515 Redland Rd - :. . < < .. : �., c. �� — `G*' "� .a �. - . .. �.. .. „ ''i%- . , .... i- , _ . . �,.T� . . .. . .
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pe.-mitcee's � j / DAVIE COUNTY HEALTH DEPARTMENT rn �� �d7
" Name: ��- �����Q r�! ���''�'�� Environmental Health Section PROPERTY INFORMATIQ� l
- ��• � £- � /� P.O. Box 848
Direc ons pr�op�y: y"� Mocksville,NC 27028 Subdivision Name:
������ r ,��,41�'� '(� � f� � ��4�� Phone#: 336-751-8760 Section: Lor.
, ! �. � � ��,� AUTNORIZATION FOR
�[�l �. �;�1 � U Eyi �G,� � WASTEWATER Tax Office PIN:# -
� SYSTF,M CONSTRUCTION �
AUTHORIZATION NO: O O L��� A Ro d N m�Y�� � Ct�C t L�`� Zip: ��r.���,
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Fomi/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
� �
,/,.��..� �� s, ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION
`'1�,�-������/�` � G �l/ ^�� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE ous�#BEDROOMS__,�__#BATHS #OCCUPANTS�_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE � � TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD)��v NEW SITE REPAIR SITE V '
GIGI i(/'1-f' 'R i%���— ,. /� _ �' ln
SYSTEM SPECIFICATIONS: TANK SIZE��'�GAL. PUMP TANK,4L IL�GAL. TRENCH WIDTH � � ROCK DEPTH �°� LINEAR Ff. ��O�
� OTHER��JI P.�eeSt },f.Q •-J �e�k�C._ ,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
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`\ AUTHORIZATION NO. OPERATION PERMIT BY: DATE: �
� •■THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTTH ARTICLE 11 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACfORILY FOR ANY GIVEN PERIOD OF TIME.
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y �s+�,� 1 - { . . . , . .. R a. • �
_ .Per.ruttee�, - f ,/ DAVIE COUNTY HEALTH DEPARTMENT •... (�/rG� �O� ,
~�"Name: r�-��`l+'` �'��l �fJ 7"�°/ � Environmental Health Section PROPE�RTY IIVFORMATIO'N
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"' ' Direct�ions tp property: �� � '�f � Mocksville,NC 27028 Subdivision Name: ��-_
, ��.. 4 .,�. :a , .
1 �. �: t -'� '� � Phone#:336-751-8760
,�? � ..e-r «-���r'1 c� � ,� f`!�, f.F• Section: Lot: �
� " -' •; AUTHORIZATION FOR � .
� :"� ,x � � ��� R'ASTEWATER Tax Oftice PIN:#
�;r�__ fL' , �'�f�/✓> >r%� r" SYSTF,M CONSTRUCTION '
<< fj I �� 1.' y � � � � �Y �,
ALJTHORIZATION NO: �����2 A � Road Name: � tf`•`.` .:��A�Zi �� �f� I�,
P�—�
**NOT'E**This Authorization for Wastewater System�onstruction 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 Counry 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)
./"�f �y' � � . ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
'°4• :'f���^��` ` �/�L�� G ��fJ ��� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIF7CATION:BUILDING TYPE - c�..+�#BEDROOMS�#BATHS #OCCUPANTS_�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIF[CATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
' LOT SIZE�,� � TYPE WATER SUPPLY�1I� DESIGN WASTEWATER FLOW(GPD)��� NEW SITE REPAIR SITE V'
-Q `'�i-��r`"' �' �
SYSTEM SPECIFICATIONS: TANK SIZE��GAL. PUMP TANK�GAL. TRENCH WIDTH � � ROCK DEPTH �� LINEAR FI'. r�O�
, OTHER_1 Y��_y►\ F-r cL �-c` ..J ��cs� �G... ,
�
REQUIRED S1TE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT � ,
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FOR FINAL INSPECI'ION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT '
--1 --- — 1 1 SYSTEM INSTALLED BY: � 'P�� �A f t�� !n
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j\ AUTHORIZATION NO. OPERATION PERMIT BY: DATE: �
� 'tTl�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANeE —
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN A�S A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCFIDO7A2(Revisedl.� ��G=L�i� �� - - -. -. . �'11��(C C:'I/Y �
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' r , ; APPLICATIO F R M ROVEMENT P RM T(REPAIOR) �� �"����`��9���
NAME �/Z!)fU �I'7���5 PHONE NUMBER q��f'�5��
� ADDRESS 516� �Gf !QA/4� KC�t ' � � � �SUBDIVISION NAME'"% �" ����� 7
LOT#
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DIREC NS TO SITE �Q rk � � � i �
N-�, 2"'iq� ��ise ' �-
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DATE SYSTEM INSTALLED 3 NAME SYSTEM INSTALLED UNDER �,h SmrF�i gurlc.���
TYPE FACILITY � NUMBER BEDROOMS J NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �/ �Q S /YIR �
S u 5" %c �� c � �
DATE REC2UESTED � INFORMATION TAKEN BY
This is to certify that the iniormation provided is conect to the best of my knowledge,and that I rstand I am nsponsible for all ehar curred from this spplication.
S�GNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/B3 �her�an �l uNw �l l bc� �dir,� u�o�Z.l�
.
D�VIE COUNTY I-�;AI,TH D�P�',R'�i�iFNT
SLPTIC TANK P:���IIT
No. of i,edrooms Date �""' � .3-- �
This p�rrr:��it is g ranted to for the installation of
t
a Septic Tank at the residence of ��� Address � _ �
G/���
�uilcu.ng Contractor r ��,.J� , -_��'�� Address _���� �;�/�!�„��
Septic Tanlc Specifications: Len�th ti�idth Depth Capacity o � Gal.,
i .
I�Zanu..facturer�s Pdame � ' � � ` �Addres� _ __
�
$lQaaL,ar __...__ ..._. � — -
P1o. of lines �Tidth��in. Total l�ngth���"--Ft. P1oe of Sq�F`t,- ��
Type o� filter material ��',,,.,,� �.-..:,r� � Total tons used ���D !�
.. . ..b
_ ,.
. %iinirr�u::i Requirerments: Tank Capacity Square rt� of Line
House Trailer Fs`00 1�00
'I1arc--Bedroom House , 800' 600
Three-�edroo�:i House 900 900
No one sha11 install a septic tank in Davie County without a perrilit from iche
Health Officer or his agente
� e ��
:��,te of final Approval �—/`/� Sign d: . �t�-�-�'-L.1
Sanitarian
I hereby certify that the above septic t ank has been installed according
to specifications.
Signed �,l,�'i=� ��_�}�'<<�
Septic Taz1k Contractor
TJote: Make sketch of disposal sys�en on bacic of sheet and nlail to the
Health Center in iiocksville.
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