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1282 Yadkin Valley Rd . .,- / w _• -- _ . .. .: . .. —�•. r.,, — ...� �. ._,. . .y„— �-- , ... ..,. --..:.l AUTHORIZATION NO: � ` l i dDAdd1E ���11�1�'�' �II[IEAIL�'IIE� �D1El�A1I8�'I�[IEI�'�' ��� �0��� '`�' � � � �,f � , ti � � ]Environmenfal Il-3[eal4h SecQion PROPERTY INFORMATION Permittee's } %`'"' � P.O. Box 848 Name: ��,�r���,/� ��.�'��� ��' Mocksville, NC 27028 Subdivision Name: ��� �/�/.' �/ Phone# 336-751-8760 Directions to property: � `,` 6��� pU�hiORfZATgON F'O�t Section: Lot: ' WAS'Y'EWA1'E1R ���^�``�' ,',"'��}"• '�� � SYST�Iv➢CONSTI2UC'p'AON Tax Office PIN:# - - _ � Road Name: Zip: : �**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmenta�l Health.Section pnor to issuance of any Building Rermits.'This Forni/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. �(ln co pliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) r , ***N07'ICE***TH1S AU'fflIOIt1ZATdO1V�O�t WAS'9'�WA'&'�62 COR]SThi[JC'H'IO1V '� � ' '�� � • IS VAL�FOR A PERdOiD O��VE Y�AYLS. � ��� ENVIRON ENTAL HEALTH PECI LIST DATE ISSUED -s.._�.:_ �.�,__c ., ... .,�. .��,,..., . .,:..;_., .. ,:._. , .. . . .. .. . . • . � , , , �`� "�'�`�.,�"'�'..��1t`f``a"""`�`,,.""Uy."y„vv.�=-+.�r^�L���K'""".'^"\r0.3'�..s:-' ,,,,,.�,�.P5�+;F{"f,.-..."�v:.1,1��.-'�y'y"t-'" ,`".'r�[3ys'�!'i"s',�'�.,'i'*;9 �.y-"''�� k�t5-.z�4t-fit..,,`,. u{ ���y... :z;�,,,,.., �,�t, .. , . � . . . , f�� ti... y.-_ . .; :'. ... -" �; '. � - � . � 9 ,; � . . . � � � ��' "'�,y r ,� '�� �.;�����'DAVIE COUI�ITY�IEAd,T�I DEPAIZTMENT � �� �"' �.. ,,��'" `':���'��� ' .` . - �pROVEMENT AND"OPERATIQN PERMITS ` PROPBRTY�INFORMATION �- � :��rm�f e s , , . ; , . �. �` . �'� "�"� �''�;`��`-i��," �l"'�`�° "#"�;�� � ' - �'� - � .'. - + :�Nam�: � ��'tr�+ � � i ' ,�� s� �= � ,: Subdivision Naine �• .. �+� , .�, . . . .�.. . . , . _ . ; _ _ . . : ,._ . ,, , ,f _ ... �r. �'r' s �;; � �� �:.,Directions�to property: �.�"��a� �"��'�?� . ��� ,' ' �Secuori: Lot: . , . . .f � ' � .- . ,�{ , ��; IlVIPROVEMENT ' •,. . _ 3�. �ry , ,,:e� r�`'�,,,. �': � ,�"�;.° ::�µ� , PERNIIT � . Tax Office PIN:# , , . • - - r � . � , , . , . ,.. . ,: �. , , . t::. � � f: ' . Road Name Zip: ` �y ,. . . . rv . � . . ., . �,� : .�—, . ,: - .: � . . � . , . . . _ . . . . ,. . ;. . .�,.� '. . ,.. . .. . . .. . . � :r **NOTE**Ttus�Im'proveinent Pernut�DOES NOT authonze the constiuctioq`or insfallation of.a septic tank sysfem orany wastewater system.�An � : AU'THORIZATION FOR:WASTEWATER•SYSTEM,CQNSTRUCTION musr6e obtained frcim this Department prioi to the . : ::� construction/installation of a system or the issuarice of.a building pernut. :, � .�' � : � � � . , :�_ . � � � (In compliance wrth Article 1 F`of G:S:Chapter 130A;Wastewater Sysfems,:Sect�on..l'900 Sewage Treatmenf:and�Disposal Systems) ^ `' _ ' •;;_.... � . �; . , . . f � ,�+� ° � �a,, ,�,�.r� W �', . ,W � ,,,.,.. . **`*NOTICE***,THIS PERIVIIT IS SIJBJECT"I'O REVOCATIOIV IF SITE 'y��•r�.�;r,� s�,,��r- ,,��',���"^�����,.�r . �,",��, �``,� ; , .PLAIVS,OR'�EIE INTENDED iJSE CHANGE.'YOUR WASTEWATER�: ' , ENVIRONNIENTAL HEALTH�SPECIALIST DA'fE ISSI7ED ;., : � .t ,,���j,LIN,I,HE SyO�M ST SEE THI$PERMIT BEFORE ,' � . . ' . �� `.'} ...�' f.n� d, �._' �,MF �..����. �^�� a•t � � '. ' ;y' � ,.• .:'.� i � •� � '�:.�' ��.�:h �Y� '.� * q,i�. : .. ..''. . '. . � . ��' �..`. .� ..�. . ..� . ... .' . '.._. . , RESIDENTIAL SPECIFIGATION.BUILDING TYPE �#BEDROOMS .� �#.BATHS � #OCCUPANTS�_GARBAGE DISPOSAL.Yes or No. . . . . . . . COMMERCIAL:SPECIFICATIONA"FACILITY TYPE� '` #PEOPLE� , #PEOPLE/SHIFT ` . �#SEATS INDUSTRIAL WASTE Yes'or No '. *.. - � +� . r: . t. '.. . �.', , : ,, � ' I ; • ., , � : . ,. . •: 'tL"OT SIZE �TYPE WATER SUPPLY, "DESIGN;WASTEWATER:FLOW(GPD) " � ° �~:NEW SITE� ' x � REPAIR SITE A�� �,.�- . , , �� ,;. .� . . , , , ,/ ��� � � >:SYSTEM SPECIETCATIONS TANK SIZE '� GAL �PUMP TANK � GAL. TRENCH WIDTH��. ROCK DEPTH� LINEAR FT � -. OTHER � � . _ . . ._ E : - , . ... , . . . . „ ' • .' . � '. .� , N .� . , . . - t ,. i� �.... ..' .-,a 1.. . � . � .. . . �. .. ` . ., , . � ��. . .,. ' . . �' ... ' . : .... . �. : . ... . . . ,... . `REQUIRED STI`E:MODIFICATIONS/CONDT170NS: '�. � � • : . .. . ,; ,. . . , ,., . ..- . , . ,.>, , , . . . .. , , , . ; ,. , • > ' � � . , . ,. . , _,, ..., . . , . . _ _ . . . ,,,. . >,'. . . ,. „ ,.. �;. , , ., . v�•, .' ' ; IMPROVEMENT PERIvIIT L,AYOUT{�,�C�B�I�CD ���Y'I�gL��# . , $� D -$F �9 v..i�L�1 {�r'I��g��� Q��'�—r'�` '.,, F, , , y , . , <, . ,, ,; .. . , . •. , ,�, �. , , ,,, �� . , . .� � . _ . .�. ,: . � , , , : , '� ', : .� 4 ,._ . ,�_. . _ Y" fi.�, �*'� _ . � . , z'c� � � ��' .�: •:� � : , _ ' ; c{s� _ �•V' +�S`. _ l� . . , , . ��, . .�.� _ � . . , . . d•k - .. . .. ,. � ., �, // , , ... '.. /.��(�/�y_.. .`! i �, fi{` •� ., � . ' . 1 . - 4' .. / . . � ! n .` . � , ' . . " , . ' ` ' j . , « � , . • . . ', i . - �. � - ,. . .. . . . ,' „ T"�. . . ///��� . .. . . . , ..: . " , ,� ..�. ... .�..�� ..' �� � . ' . . , .. . . .. . . . . . , N ` .' � ' 'F . . . . . ^_ .. . � . . . � M1y � .. . ' .. � � .. : . .Y' . � � , . , � .� ' � . _. . . . . . . � ' ,'... � . , .- . . . , � . . . . ..._ . . � .. . . . •y. ' �i.. I. . . . . . .. � . . � . � �]':J .�j._:.. � 1� � .:. . ,_� .n .,�... -�.��.- .i � .. . � �. . . � . .�. �� " e ' � �. I� �� ' . . �. _ ... . . . . . . . ' . . .', � . . .;. . � � " "' **CONTACT A'REPRESENTATIVE'OF.THE DAVIE COUNTY;HEALTH'DEPARTMENT.FOR FINAL INSPECTIONiOF THIS SYSTEM�.•;� ,�� . .. , �, :. _ ,, " BETWEEN 8:30-930 A.M.OR 1:00-1;30 P.M: HB DAY OF INSTALLATION.TELEPHONE#IS��'6�$�bf ' . t�36.D��fl-��fis(� .. , .. , , , . . � , � . . . . „ � f. . .. ,.. �, OPERATIONPERMTf � " , :_ r: . . , . �. __ , � , . ,. .. . �. •r ' ,�.., � �: :, .. , SYSTEM I LL BY: , ' � . ' � /�� �X� � . � r � .,, : : . , .. -�� : . . . . . . � � R � . , ,� . �. . . . ,. , . , � . : , . . �. : � . , . . . �p.. . - . . � ; - � , . . . v . . .� , , ., �� � .. . ,;; , ., , ,,.- -�. , .. . � - . , � , - - . _' . . . . . . "� . �. . . . ,.. ' � _ . ' ,�,3'�,. � � � ��� i) . 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"`*THE=ISSUANCE OF•THIS OPERATIQN;PERMIT SHALL.INDICATE THAT THE SYSTEIvI DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANGE�. � � WITH'ARTICLE 11 OE•G.S:CHAPTER 1�30A,SECTION.1900"$EWAGE TREATMENT AND.DISPOSAL-SYS.TEIvIS",BUT SHALL IN NO VJAY BE`TAKEN:AS A � � � GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY'GIVEN PERIOD OF TIME. .� „... . . . .,. . ..� ..... .. _-� . ...�,. ��� � �. DCHD OS/96(Revised) ' _ . . ' ' ' ' ti , . . . �.. ,- • .� , : ...t^ • , . , . „ : . �'�= � .... - " ., , ^ . ' , — . ,. , , ., _ a .. , . e , . ... . , . � y _ a'• ; � . � . , � -�. . . , • . . . . . . . � . . . . � . . _. �. ���. . . , � , . . . " . ._ .., � ,..., . . . ..��J t t.�.�mF�..�!, . . ... �� . .. ' .. .. ' - . , . . . . . _ , � . _ ° . . ,. . .t,.. � � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION � � APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) � NAME � 4'r�,l.� �� �2-7�<' .� PHONE NUMBER � �' ADDRESS �S � � ,.� v�/�{- �� � SUBDIVISION NAME � , �� � a�, � i v �� LOT # � � I DIRECTIONS TO SITE /� 'I s� I DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER �I TYPE FACILITY NUMBER BEDROOMS ' NUMBER PEOPLE SERVED I TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING � � li � DATE REQUESTED � - � L INFORMATION TAKEN BY 9 P� I-�— � II Thia is to oertify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application. � � � SIGNATURE OF OWNER OR AUTHORIZED AGENT � Fev.1�93 . , /2�`'� �.`'� �� -7 i A- �