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164 Taylor RdAUTHORIZATION NO::�` J1 AVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFO A -TION' / Permittees (� � ,�/� 1�L P.O: Box 848 /Sq � f — % g"_O)LName: �� !' i Mocksville, NC 27028 ubdivision Name: Phone # 336-751-8760 Directions to property: l'� 'T -c. t� a' Section: Lot: 4 AUTHORIZATION FOR l A,-1 I or..i ��: I% t✓� WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION — 1. t-X:''ti-UNCC H :. i f.:� �� A`1't�,rt. Road Namte I �4t_a f-�= 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) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION (4 IS VALID FOR A PERIOD OF FIVE YEARS. E�TVFI ONMEN�,A LT .SPE IALIST DA E I UED Permittees t Name:;,f ; Directions to property: t , /JDAVIE COUNTY HEALTH DEPARTMENT i IMPROVEMENT AND OPERATION PE ITS PROPERTY INFORMATION"` I ' A ter° , V'1 1 Subdivision Name: UYIPROVEMENT " -i .,, , , , ,„, " i t . PERMIT Tax Office PIN:# t h. Road Name: Zip: _ Section: Lot: **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 )Si # BEDROOMS 'Z— # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No R LOT SIZE' X-� ""' TYPE WATER SUPPLY L ,ot),-J7 DESIGN WASTEWATER FLOW (GPD) !�Ny NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEV GAL. PUMP TANK GAL. TRENCH WIDTH —fin ROCK DEPTH 121LINEAR FT. 2 C o REQUIRED SITE MODIFICATIONS/CONDITIONS: I & 1G n FF 1" Q LP tw-i ►Je . t" �r � F c� W L,,_ IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUSt'IT FILTER* *RISER(S) IF 6" PELOt1 FIPIISHED GRADE* L'AAILC14 C otZI Ttul a wx+'��' 5L hic -IAr-W_ . 1F ~1 if namf wl luvU 6tU_._1 A-"( L 1 ow_ >T our, �, ... "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 (=i(�hjtac��3 yee (336)751-8760 OPERATION PERMIT Iy I v 1 �''1 l•T SYSTEM INSTALLED BY: J►—� I P�3 Z, 1 LLaw- 7 'N�Iao AUTHORIZATION NO. OPERATION PERMIT BY: DATE: I I, "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S TEM SCRIBED AB 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 05/96 (Revised) D ��0 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Envifwmwta/Heaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 b��'�FCn�,; (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS L THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Mailing Address City/State/ZIP 2. Name on Permit/A Mailing Address Contact Person Home Phone r� — 2.3 R 'CBusiness Phone 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. system to service: fer House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms �_ # Bathrooms ❑ Dishwasher ❑ Garbage Disposal W Washing Machine C7 Basement/Plumbing ❑ Basement/No Plumbing 6. if Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats// Estimated Water Usage (gallons per day) 7. Type of water supply: V County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 'qIo If yes, what type? 'IMPORTANT' CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: -I ©19 3 00 Tax Office PIN: # Property Address: Road Name City/Zip 914aaczr . If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksvi) to PROPERTY: h.- , n =T / r 92 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 are 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 am responsible for all charges incurred from this application. I, 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 I-- Y -Z� 62.. 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). yza3 Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. ° _' '7 / Invoice No. `1-7 a