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1017 Williams Rd ��� . .. �� -� a , . . �-.�-�.� , , _ . . . .. . . , .. . . .. _. :. :r . . ... . . �: . . ,. < ,;_ o..: . . _. .,, ... . � .� - . ... . ����'�,r ��c� : ,AUTHORIZATION NO '1 �� � �'�'DAVIE COUNTY HEALTH DEPARTMENT �/.� • Environmental Health Section PROPERTY INF MATION � Permittee's ^ � n �, P.O. Box 848 �1-�� ���..__. Name: � �17� �-4'�'�'",t—' , Mocksville,NC 27028 Subdivision Name: Phone# 336-751-8760 Directions to property: k- � .t�h1`�;►?�� Section: Lot: /� `' AUTHORIZATION FOR �=-+� � v;,J �- �IL.LIb,��. WASTEWATER Tax Office PIN:# _ , SYSTF,M CONSTRUCTION - — . ��;�-7 �,,., Road Name:__��11-L1 Ari�, EJ_�Zip: rL. _i�(r: **NOTE**T'his Authorization for Wastewater System Construction MUST BE ISSCIED by the Davie Counry Environmental Health Section prior to issuance of any BuildingPern�its.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applyin for Building Permits. (ln complia��e;wjt}yArti e 11 G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) f' ; /'1 ' , ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION . '�,, , � � ( 1 U L IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRO M Tr� H SP C t�k i}ST DA E ISSUED ` `� 4F, �en>y�. � : ��[' '�.x.'"`" �rc'va++ r Sdi'- x r, fy�• -�-�i� .rm-.+y ..�- ^�'Zh�i��,`a.�.-a'�.�.;,��'rL-�!'rr,�s�-+•`-�.."-"*��,t�-r,.-rUrr ,.t� r�`�-.✓^� n ,.,—a .�c:.,�..:.t 1 a "',+`�4� t5f� y .. � I.m "� .j'y T��. , r ,,. � . . :� .`, \. . P'y� � d .: �M1� �h...9:` � ..�L ��k -.a! � T'i C }����y� � A /� pT �(��g . p.. • :/� pT/,�- � � . '�� �-��� i�dr. , ��4� � k S k� �����YJ��YH�.V,��1 Y�tl 1Y����HH'�����Y 1�H�1\L ��i � . ,k.w,,.r `� -.j• . . , . � .-.. , . .. � :����'.-�' �� : : ° ,� .. �1�1P�tOVE1��N'�'ANID O]PE�iA�'�OM�E��'�'S�;_ �PROPERTY IN ORMATION ��'� �=Pe�niftee's ��'�" �`�� •:f ` . ' . ` � �!—�� `�T� flf. . .. : �..,��:Name-:. � : -���,��� '; �.��.���� � �� ' . � . ��� Subdivision Name � � o , , , � ,� � � ,;; ��� ' '��"`�_�:.. : . � ` D�rections to pioperty:; � r'_�� ��,_ � ��t �.�� .� Section: �` Lot �" ¢ ,� , _ t�,.� __ '.° Il�ZPROVEIVI�N'f' - �• � . °. �"�� �'�,,...r�,�i�� `�t�.�f` c-���!�`h..1���^;�. ;PERMIT. ' � T,ax Office:PIN:# - - s �"�,; � * . 2 " � . ���� ;� ; � ;.�„„.- . •Road Name. �"r..�i�.�� ��'�, �r Zip: '.�� ��'�.ra ... ; , . . „ . , . ,; . : , . . , � ,�. - .,, , . _ . � : **NOTE*.*Ttiis ImprovementPermit DOES NOT authonze the construction or installation ofa septic tanlc system or anywastewatersystem uAn '' "� °��•ALJTHORiZAT'ION FQR.WAST'EWATER SYSTEM,CONSTRUCTION rriusf be obtained fr�m'this Department,prior to the :constructionhnstallat�on;of a system or the i'ssuanee`of a'building pemut ' �` ;- ` ; `, ,' (In comphanee,�itli.Amcle l l:of G S.Chapter:130A,'Wastewater-Systems,Seerion 1900.Sewage Treatment'and Disposal Systems) •, t�. * :_,��n �e.` � ' . ' ',? � �'� a � � �'�'' � , .***NOTICE***'TH�S'PERMdT'IS�SUB.TECT TO YtEVOCA'ITO1V fiF SIT'E � ' HS I • . ,�,����.'`� � ` ,,aj� � �� �'i�i��°�,2�. PII�ANS OIIt THE INTE.NDED,LJSE CHANGE:.YO[JR WAS'Y'EWA'I'EBi . �4� , � ,.ENVIRQNMENTAyL�HE{A�i; 'SPEC��IrAIsIST DATE ISSUED � , SYST'EM CONTRACTO�MYJST SEE�TI�IS rERMi'�EEFO�" �� � T 't�+F� t.i ,i^' h � - i, . ,. . . , , . .���� ..,.,7£ ..` P3�.�'.. 61'{� .. INS'p'ALLYNG T�SXSTEM : • • �` w � . , c �� '�� �' � .. �- .� '. '• .� ;: ; . ,. ." � � ' _ ;. . . . _.: . . . -� . . ,. . ., . � , � �RESIDENTIAL SPECIFICATION.;BUILDING TYPE�#BEDROOMS_�#�BATHS �" #OCCUPANTS�GARBAGE pISPOSAI, Yes or No _., . _ ,, .:, j , . . " - �" " . ` � , , . ' y .. � ,* . . COMMERCIAL',SPECIFICATION:;;FACILITY TYPE #PEOPLE #,PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE Yes or No ' . a � . � ,. f . .. � ' � f .: R .. �. t . i.�. { k . j � 'Y .h�LOT SIZEr• �]��Y.PE•WATER SUPPLY��i�f+' �DESIGN WASTEWATER FLOW(GPD) �U� NEW SITE' � REpAIR S1TEi +� � � �, .; .. ..., , ..., ..� . , ..` �.. ' . ' � , 1 . ..� .. .. ._ ' :,��, ' . . •' .- ' �t . ' �' _ � ... .,. ' . .. . � . " ., ., !' , .. � �; � . .. -... �, ; . . - . g 3 '�",. : SYSTEM SPECIFICATIONS TA.NK SIZE N GAL. PUMP TANK GAL.� TRENCH WIDTH'�� 'ROCK DEPTH 1� LINEAR FT 4�� _ , . . OTI-IER ����` l..C�.N�r�-�" ^� �P.� I,.���:' l,.!+:�� .. r � • , . . - .. ,,a ; . . , .. . -, .. ., , , . . • � .. ; ,� `. � - � - .• . :, , , .` , • , _ t - • ' �. :' ' ,� c`��J . c.o w 1`oJR , �� J��2 i...�PJZ �y�'�' � ,"`: � QUIRED SITE.MODIFICATIONS/CONDTTIONS: "!��&U- . ,� > _ . . .. I 3n.. . � r .. q - .-� - .. Y . � ._Y . . . � _ 'y. .�: ..�,• � ,. . . _ . , _,. . . . , n . . . . .. . _ . _ . . '.' IMP-RO,VEMENT PERMIT L � `U'T i���D�FI�•�(��.���"��Y�:.���'e�.i'r�$�R�Q.�`� �g����a9�9�';�L�.,����I�l�`<:L���'�'` �,� " �, , .. , : = ,. , _ „ „ ; . .. ; . ,� . ,. . •. . . , , :. ., , . : • , . , . . . . . . . . , .. � . , � . ; _ .-. ; , , . ,. > _ . , , R. . , ; .-,. � . . . , ,f . .. , .:. . , .. , � - . . ,, . . .., .� .,; , . , �. . , _ � ,, ' , . , . . . � , ,. . . . //� .. , �g .i . • • L. . .. - ; + . . .` '. . .- . . . . ., �y . .;L=1���� I n „: , e.,e ; u � �r C?tl�j'"�T„J , � �, , . „ . ,: . , . � . . � , , . , : �_ .,� . �„ , . � . �. . . , � t: 1.� , � �, ' ' , � �� " � � ., � .�.+►r � r . . . �. '''..� . . . � p Y � �� [ i s � ' ' . . , ' ^'�. .,.�Y �. .' . . e . �f e , ��� ' . � ���a�� . . �� . . .-w�t `_ ��' � � $�`^, . . �", �IN . , _ —1. , ,i v , ' , �' � '.��.-tJ9 ,� ' .� } ��, .,. , , . � �. . . - � , .. '-�, :�1�.�. ��:.� � _ , ` ' . ' . . :`, � T, � , ' �r �-1��j�tA� .�� d�.�����. v , :, ; ... „ . . :. . . . . „ ,' �, , , . f �, , _ . . , . . , , , „ l.{r3 . � .-� ,��� :. . , .. . , ;. . - .. : . _ . • , � y. o . ,. . ;. , . . . � �.� �� t�-` �� . , , . , „ . � �, . �v . . . . _ _.. . , a ,. , - . , �,. . , . • -� **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH�DEPARTMENT FOR FINAL INSPEGTION OE THIS�YSTEM . � BETWEEN 8:30 9i30 A M.OR 1 00,,1:30 P.M.ON`THED'AY OF'INSTALLATION�TELEPHONE#IS(��J�3���1. �' ' . �. , , ,.. . , , . .,,' .,.. . ,; -. -..', � � . . . . . . .. �q a . . . - . . -. .. 'Q� � '!�I�� . . . . . _ .,. . .. . . . . . . ,��__ . ., . . ,., . . . ,: . . . . _. , . . , . .:. . ., ...�,�,-. y� . , ,.. . . '. . . . - . �. .� ,,. . . ,� . �,. . �..�. .- , . ��: ; �.. . . . . . .. . . . . . . . . 'OPERATION,PERMTT� - f ' , � . , , .. . : _.. ` -r � , SYSTEIvI INSTAI:LED BY A�n� ���� ; , _ . . , : ;� . . . . � _ , � ' , . , � �, ., . ... ,. . . �. , . , , � � . . . ,. � .: � . • � �° . _ „ . ; � h�* P . . . . . . . . - . - , . ,. ., . , _ ; , , _ ,�: ,. - _ .. ,. : . . . - . � = . . - . .. � r . .. , . . „ ,. . . . •. r ... , . . . _ , ti `� , . �. . � �., .. s ,. . � .: ;�,,. �� ' .:? �. . .. . � _ t S " �' - '�`A '�� �_�Q'ti..�� - ' � . . d � F _ 4 ° 6\u �.� �v �:fi - s� t �. .i ' � ..- �. . 7 ,, � . * �`��,_« ��` ti S "�� � ` � � ,1 t�.��1 '�, -�0 . � , , � �T`� ��'^�°� `�� , �. . . , ., , , , .: . , , . , , . . , , � , .. - . z, _ . . . , ., . . ,. , � . . . , , .. ., � : . . v ,:: , , ;, . . , _ . . , . . � : , . ; ,. . , . , . � . : , ` - . . ... : . . .. ' . ' . - - _ � , �� � i.i 1 . . , a�. . . . . .: ♦ , rv. .. . � . . . � . . . .. ... . ..� � ��. . ` �. . . '. '� . :.t. , . � � . .. � _ r�' . . . � '�. ;.. -: :: �. ' .� , �... .. . �.. � . .� ' _ . . F. . . ,. . . .. ., �L � ....�. .. .. . . . � .. " 5. q, . '�i, " � �' ' . .� .. . . , . � �_ � . . � . . . . •� • . t. -� .� .�' , , � i, � ' ' a ' n . �a y ^ ! ': ... J' . ,. .. , . � ... • r . - .:d . . . .. ' � ' - . �.�. . � , _,. .. . . . _ . ...r ..: .� �. .. . .- . . - . . e ., .. . . , „ _ , . .. + ,. . .. . . , . �� . . - . . . � . , . o s . , . ,� . . , . .r � , . - ...: '�z . ^� �. • i .. . . - . . . . . . . . '.�. y" �' . . . . . . . . . . ..t . . . .. , ...v. . ., :. . ., .�. . , . . � 3 J 1 � ' � .. � / e, 9�! � �/ � AVI'HORIZATION NO.c-���OPERATIONr:PERMIT DATE `��� . ., . . . . , , . , _,: . . . �, . . . s, . � .: .. , . �, , ; l �� � . , . . .. . , ... : ; „ ..-�- .. .: .. r : .. . . . , , ._ ..:. ,, , . , . . , ,, . .. . � . , •� **THE.ISSUANCE OF THIS OPERATIONPERMIT SHALL,INDICATE'THA,T SYSTEM DE3CRI D ABOVE;HAS BEfiN,INSTALLED IN COMPLIANCE <:� , a �' WTTHfARTICLE�1_1 OF G.S.CHAPTBR 1`30A,,SECTION:1900"SEWAGE TREATMEN'I'AND DISPOSAL SYSTEMS";BUT SHALL IN NO VVAY BE TAKEIV AS A ..' GUARANTEE�THAT THE SYSTEIvt`WII.I;�EUNCTIbN SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -, . - --, .-, ..r; - ., . ;'DCHD OS/96(Revised) ,. ° � . . � . � .,-. . � .e -, .. ; . . ^ . .. . ., ,, y '.; �.. . . , �` .. . . , -. ,, . � � r � ,__ ,-. , . , . . • : e . °� ' , � ..� , , ,, . . � . . . , . . . . , „, .. A: � , .. � , : _ :, . , , , _ � . . . � ° `� � � . - � � �. ., . , . . . , • _ . . rt . . ..� ... �,� {r . ; �,� DAVIE COUNTY HEALTM D�PARTMENT ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION J�� * TE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number •- ,. , ;� , �. _ Name '�" ,T.. . ,., /. ,� i:,�,�;;. 1-d) `r,-,T Date � -- — `" f . j� ', , .. Location � ; '� , `� �. . , � _. . . , , � Subdivision Name Lot No. Sec. or Block No. Lot Size� House - -'` Mobile Home _ Business Speculation No. Bedrooms _ �� — No. Baths _ '� No. in Family_ �,"J _ Garbage Disposal YES � NO p� Specifications for System: � � Auto Dish Washer YES NO p � '� %-" �� ���`�'��''� . Auto Wash Machine YES � NO �p //����� �..��,�'� ��E- ;,�,�-�, .-� ..;��� �� �����X ��' '' Type Water Supply _— � 1 `This permit Void if sewage system described below is not installed within 36 months from date qf issue. =-\��_��� � �._ / r�r I ��.�..._ /� _ __� � �� �..__..--- �� - �_ ����� - �� �� � r �� � � 1 �:�_�� ' � ' - � y , � �" __-----._---_ ► - � 1-� � ,�_._�,._..._.__.. _...__� __.._...--.____._._.�....,�__ .. .., �. . ,_�.. _. _._ .. V.__, , I ,� ____.�._.�_._ .__ �' � _-._..___�______._-- ,�'"��/rr �/P/`�, Improvements permit by _��'' , 'Contact a representative of the Davie County ea h Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of com etio . Telephone Number: 704-634-5985. ' %"/� <=�:,/'_ f Final Installation Diagram: System Installed by,%.:%�:-�I�? -;%%%��/� �_ � ��,� ,• �� �' L� .— �,r//.�sJ //;ri/� �� l/ .!�t<U / -} ,/ � /� -� ,� `:��.") , , �- .�'� -,J- r�r %� �� ,-' ".�,.—�� —'" . ; ,n' �.,t,,;� /' �- ; � %` /C'' ,,' , ,�-- ,� � , ,; �- � , _... �.i . � (� / �`�— � /� �-f;i. �' � � ( `� � � ���ll / �l,�'-'�� �l� ,,�%L-l � '� --- �/ '� . � ���/i ,'•--,i -- Certificate of Completion , ��� '�'{ � Date ��.�,��-� "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. c'[�c� n��'� t '� '� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION +_ , APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME �� f"� ��O��-� PHONE NUMBER � �� � `�--9 rr` --, ADDRESS /'�/� (.� �i /�4.�-s 2-� �-�t ✓� �-�--� SUBDIVISION NAME � � LOT # �.9- DIRECTIONS TO SITE �v `1� �" �-�� � ^' �� � ►-� �'ur � .�f-Z�r•- /`ll 1� � �.�-+ ��� .u.,,., �e�. F��--•.�`f--- ( c� �,,—o S J f-. pru., � �� �'s c ;...� m �d 1� c �,✓ � 1''�-t�D�p !� !7 .v'Fv /� .,� r: ' i�J'v�. $-T o iw`. �,.�'�'p•/ � f DATE SYSTEM INSTALLED ' �'' �r � NAME SYSTEM INSTALLED UNDER � T� onh�e.- L� ra ./ � TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED � TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING S'e �..� � u S �e P ��� � c,�- +a.�L. � ' ( _� ,4 �` � �^-�- ��v l,s o �.�l i s �a-�--a ��/�'r a DATE REQUESTED ��yl� � INFORMATION TAKEN BY !J • � • � �� This ia to certify that the information provided is correct to the best of my knowledge,and that I underetand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1�93 ` �( ��� �� y 9�