1005 Yadkin Valley Rd . � : . . , �'�o
AUTxoRI2�'rION 1vo: � �r J� � DAVIE COUNTY HEALTH DEPARTMENT
` . Environmental Health Section PROPERTY INFORMATION
Permittee:s �,f r P.O.Box 848
Name: ��i'�l�. �.h'r?,1�S� � ���SG'i'-:--�^►j �' Mocksville,NC 27028 Subdivision Name:
� � ��/� Phone#:704-634-8760
Directions to property:�e��-��/�����r1 Section: � Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTTON - '
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Road Name: � � �""Z�p! ���o
**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.T'his Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pernuts.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
< ^1 �"1 �� j ry ,. ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
[z',�- .�' ,,1., �,,.�.s:- , "'`�j�
/ !,r`'.[.� % (,: ��,.:3'�� �j,� Cr ",t_S `,, L IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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'� �� ''�°''F� ' iMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION �
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'Permitte�'s � � : '
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` :� Subdivision Name:
Directions to property: •��'�'�-����'�•',`�f +�'j�' �,'� Section: Lot:
- / IMPROVEMENT
' " PE�T Tax Office PIN:# - -.1- �
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Road Name: l/��I��4/�'j �'�Y"'"�p!��C�
**NOTE**This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWAT'ER SYSTEM CONSTRUC'TION must be obtained from this Department prior to the
const�uction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
.�•',: w�,�r" !�'M f ,�,r , ;�-` �,.� j ... ..,,,_ ***NOTICE***THIS PERNIIT LS SUBJECT TO REVOCATTON IF S1TE
; � f;�� � :, r ��,.+',i "s"1 � � `�:/ , "r'''� '' PLANS OR TI-IE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TI�IIS PERIVIIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFTCATION:BUILDING TYPE_� #BEDROOMS.�_#BATHS�#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE ��"`
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SYSTEM SPECIFICATIONS: TANK SIZE ��a GAL. PUMP TANK GAL. TRENCH WIDTH.� ROCK DEP"TH� LINEAR Fr:��
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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**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(704)634-8760.
OPERATION PERMIT ` ��J o SYSTEM INSTALLED BY: i�?/4���- �/f�t:l,l/Zp
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AUTHORIZATION NO. l�`� OPERATION PERMIT BY: .�C r�. 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.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 SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96(Revised) ,
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� -; �.`'"�n_ E� � �'��;� DAVIE COUNTY HEALTH DEPARTMENT
p���. :"-"`y�� TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION �
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Pertnitte�s .
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Name:� �%�%;� ''� i.r:; �', `"� � �`';� � l Subdivision Name:
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Directions to propeity:.��"'�� {� �� ^`- } Section: Lot:
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.% Il�IPROVEMENT
" PERMIT Tax Office PIN:# -
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Road Name: `'�f�•�; �l`a � p����iC���^,
**NOTE**This Improvement Pernut DOES NOT authorize the conshuction or installation of a septic tank system or any wastewater system.An
AUTHORIZAT'ION FOR WASTEWATER SYSTEM CONSTRUCTTON 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 S1TE
�. �` ,. %�•4 , . ; _� PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACfOR MUST SEE THIS PERNIIT BEFORE
INSTALLIlVG TI�SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEDROOMS�#BATHS�� #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEJSHIFI' #SEATS INDUSTRIAL WASTE:Yes or No `
, LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE G'`"
� : �- '
, � .p ,-, �
SYSTEM SPECIFICATIONS: TANK SIZE C��D GAL. PUMP TANK GAL. TRENCH WIDTH �S� ROCK DEPTH� LINEAR F�� ;
OTHER -
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT �
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**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(704)634-8760.
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OPERATION PERMIT `,,,�f � ��'` �
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AUTHORIZATION NO. ��.� OPERATION PERMIT BY: _�„� DATE: � '�n '
•*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 OS/96(Revised) ' �
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�. , � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION /9��a9�� ���- �
��/;� ��` OR{�S�EE F�SEPTIC SYSTEM REPAIR PERMIT ��jg-a+�a� ��'
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NAM PHON UMBER �� � c��
ADDRESS D Lld � El. �e �SUBDIVISION NAME
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SUBDIVISION LOT#
DIRECTIONS TO SITE � � � � ^ GtG��
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DATE SYSTEM INSTALLED l0� �
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NAME SYSTEM INSTALLED UNDER
SPECI PROBLEMS OCCURRING � / i � C 1 �
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DATE REQUESTED (0��7 � l � INFORMATION KEN BY �f�
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