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293 Willow Creek Ln (2) _ Perr;jittee's � .j DAVIE COUNTY HEALTH DEPARTMENT ,��/ �l° �`� Narne ��� �*-t�') ;�1�'ia-�== Environmental Health Section PROPERTY INFORMATION ` ;', , , , P.O. Box 848 ��� , .., �Directions to property: t �.i�I` ��� �JAJ,r3 �t ,� Mocksville,NC 27028 Subdivision Name: ` �.., *':nl �'�'��^g `-^rt�ei"^ti �'; r� .,` <; r , . Phone#: 336-751-8760 ; �r� �,�����r�a.��} � Section:� Lot: �� ` ,`—' AUTHORIZATION FOR ��-Z ,w �.,� �¢.��4 �,��''� WASTEWATER Tax Office PIN:# _ _ ' , SYSTF,M CONSTRUCTION k"'� !'y �.'yr� ,., ..y..» � r �a'r� P� AUTHORIZATION NO: �n � ��= A Road Name - t'"v+��Et�-r��^��-�-�"2ip�" r 1L�.�' **NOTE**This Authorization for Wastewater System Constn►ction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Forn�/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (ln compliance with Article.i l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) . ._.. ; �r ` ��- '� � „1-3'' ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION "f rI,r �'l i�A yy� � '.::,.-��-�""""'-�� (: 1".: IS VALID FOR A PERIOD OF FIVE YEARS. �� :. ENVIRO)YM�`N�AL�l-1E 'TH SPECIALIS�„y%DATE ISSUED f RESIDENTIAL SPECIFICATION:BUILDING TYPE . /�N1�� #BEllROOMS�_#BATHS � #OCCUPANTS �-- GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE�•�� '"'�YPB WATER SUPPLY�e:-1�1.- DESIGN WASTEWATER FLOW(GPD) �-�%�� NEW SITE REPAIR SITE � -� r� �� � SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL: TRENCH WIDTH�-�✓ ROCK DEPTH � LINEAR FT.�� � > Q�,�,� r � OTHER 2. ���T'�-1�IJT��rJ l._(�C.C� � I►'J��:A.l.L l...i r,��:r C.,� ('�).C.�'_. f+.t'�,�. r r,, REQUIRED SITE MODIFICATIONS/CONDITIONS: ���T��- � e"�'�'L l �°`�"� � ��f�f i��%������ �r 1=�� `�-�"�✓ �' �y�1, Lr����i—C.. IMPROVEMENT PERMIT LAYOUT y'��C.4�t;.'-� Gl:�"��7�jln� U� '"Sl�,r,���! / , �?c:�C'1.��. 1F" ��e��.:;� �� ,�..�.�.�'����� r3a �. 4 C{.�� �� �/'� �. ';�'���;.[✓i� i.1 rt'.w�;. �T.) C,��,i'�-;.�?, � �� /i �- ,��,�� � �,� ��, � �c.� / �� — ��:��— � j '���3 � **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 (336)751-8760: ' OPERATION PERMIT f/ `� SYSTEM INSTALLED BY: / L �` (/ . � AUTHORIZATION NO.�-�ERATION PERMIT BY: 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. ncHn ovoz���8�a� ��` '" �- ��.AV�'a" � x z x' � � � �"-'j�`�"J� ��.��� �&,.'. 3`��e-�r���; . r•':� s��' � a '_ �� �:. z ��i t� . � .,.� � �,� � ,e = � w r '�Y '�. € . � . 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'i�';:. � ,G<�� � �.�x:'� �_���.� ���g� ,."e`"..'.' �_�mnz °i� �t�, � �4.���r». ����.� � r � : � � a . � �" '� 7 > ° . � ,� • ,� . � � �" � � ' , .... �,: �. .. .. �..g . l.— , . � .__----- �e�_. ,. .�, , � � ��r � . _ . � Q `/.':1 Ci--iS � � ��� � �'"�_`" �'����7,r , , y�- -��'� DAVIE COUNTY HEALTH DEPARTMENT � "�'-�-�-�-.�.L�� � / J �t� ��`+.,� �, :. Environmental Health Section � fA�_ � � � k ''�� � PO Box 848/210 Hospital Street �' 2 '°3 � � � ���"`����d� � Mocksville,NC 27028 °`�;�- � s �, ..r' E! �,,, :--,-... � ,� �2 � Phone: (336)751-8760 � 14�'�Ti;�Jr,�;��TH� � �� ..�;-�..�� �` ` `c:h�'� � ,�- .' O�i=SITE WASTEWATER CERTIFICATION FOR DWELLING 't, ;�a�'1K .s'' fr,-,+ ,�;•= ��R �.,,/�C�he�lc}One) REPLACEMENT❑ REMOD„E�.�G ❑ RECONNECTION ❑ � Nam� ��e�-� �7�- L�- Pno e Number: � � ^� � �� (Home) Mailing Address: „nZ `� � l� L 1 ( ��.-� C K. C.,I✓ �� J^-/ y�0 (Work) u C �S l l(-�. Jl/L Detailed Directions To Site: <Q o � � � ccr ,�,�- .� ,�r A-�;� G� � w , � �o� c!L � �-� r,� r i� e� �r- I�e -�- ,— Property Address• � � � L � �,'L� � ��..� � �� L—n� Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: ? Type Of Dwelling: �°J / "`� �"�d c� Date System Installed(Month/Day/Year): �• Number Of Bedrooms: �'�Number Of People: � I Is The Dwelling Currently Vacant? Y No❑ If Yes,For How Long? Any Known Problems?Yes❑ No p/If Yes,Explain: Please Fill In The Following Information About The New Dwelling. Type Of Dwelling: � �/`�-�i• �� Number Of Bedrooms: � Number Of People: 2— � /� � S� Requested By: Date Requested: (�re) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ � Comments: �S-Sl��`� �4)K. Y:�.w�,�; 1� �p�p�j � � i �� � Environmental Health Specialist Date 03 '�The signing of this form b the Environmental Health Staff is in no way ' ended,nor should be taken as a guarantee(extended or ' 'ted)that the on-site wastewater system will function properly for any given period of time. ��' ( O .� Payment: Cash Check Money Order❑ # Amount: $�� Date: Paid By: �,.r_ Received By: � Account #: �� � �1 Invoice #: � �- �� l/(,K�� �'-..' �j� � `� n/L(., c� �ir'`r'�" � J d � llec 1� U1 U5: 5Ua davie count� envhealth ��b 'I51 8786 P- � � 4 D�1�� COUNTY�I�I,T�I DE��4�tT.bI�1VT ENVtRONMEl1CTAL HEALTN SECTION PO Box 848/210 Hospital Street Courier #09-40-06 M�!ssv�7�a, N� 27fl2� ..: Phone #: {336)?5i-8760 �:. : :. Decemberl2, 2001 Susan Parker Pruderrtial Carolinas Realty 4156 Ctemmons Road Ciemmons,N.C. 27012 Re: Sewage System Check :; Buyer: Albert Gales Dear Ms.Parker: As rec}uested,a representativa from this office visited the aforementioned site on December 1],2001 . At the time of the visit,there was no visible indication of any effluent from the sewage system on the surface of the ground. Please be aware that the above statement is in no way intended, nor should be taken as a guarantee(extended or Iimited)that the sewage system will function properly for any given period of time. PIease advise should this o�ce be of further assistance. S incerely, �'��--�'�_ Clint E.Dorman, R.S. Environmental Health Section Enclosure(s)