161 ShallowBrook Dr Lot 54 DAVIE COUNTY HEALTH DEPARTMENT
' (Septic Tank) Improvements Permit and Certificate of Completion
}. (Ground Absorption Sewage Disposal System G.S. Chapter �t5r ticle 13C)
OWNER OR CONTRACTOR ,q/t `ti1 J11J!° ' DATEAA-f � PERMIT
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LOCATION77.
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1\ 1 J
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ; MOBILE .HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS �' No. BATHROOMS :23 Two Bedroom House 800 Gal. 600 Sq. Ft:
GARBAGE DISPOSAL UNIT YES 0E NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft
Four Bed- q ouse 1000 Gal. 1200 S
AUTO. DISHWASHER YES � NO ❑ � q• t.
AUTO. WASH. MACHINE YES NO ❑ }t ► '
SITE SUITABLE YES D10 ❑ + °�
�, # f lal�M�G�rvr
SIZE OF TANK ,,' ;� ;��.gal. �,,,
NITRIFICATION FIELD o�� ;`sq.� ft. Gs�' '`' ?
!,:`w rWd.r t'a�y«4 .�`: .,, 4•n ��� +^�.� ,..
DEPTH OF STONE IN LINES:; r 'A" it .0,. ' �'Lte' `" s ✓ '
WATER,SUPPLY: Individual-.' U ,, ,Pubi ,o. Gr p, �tt.G` r r!,� ".� •. '"
IMPROVEMENTS PERMIT BY pt ,,.�/Gt,a,, y ,.
�- �:INSTALLED d BY•= '
CERTIFICATE OF COMPLETIONBY Date �p
(8/16/73) *Construction must comply wit al�qhe�rapplicab�IeState ndlocal .regulations
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT
L
P. 0. BOX 57 l?�
HOCKSVILLE, N. C. 27028 7/ l
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations ��
NAME ,G' DATE ISSUED /
�` ADDRESS-,CQ� PERMIT NO. /
. Explanation of charge
a
AMOUNT DUE Js SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME DATE ISSUED 8�
ADDRESS S�/ PERMIT NO. Q
Explanation of charge A A -
AMOUNT DUE 14& SANITARIAN Q
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT. �`
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
►. APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME O "F f=4 1 PHONE NUMBER
ADDRESS / �f ( SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE 159 fi0 LAJ aR A S
EI ro% 3j::'t b t.P-J- 0., ryl a L- 6z
DATE SYSTEM INSTALLED 7 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
U r6
DATE REQUESTED ��' I+ 0� INFORMATION TAKEN BY
This is to certify 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
Rev.1/93
Pe
i:ttee"s -`n DAVIE COUNTY'HEALTH DEPARTMENT
rs✓
16 Environmental Health Section PROPERTY INFORMATION
C' P.O. Box 848
Directions to property: `'i + • 1�. Mocksville,NC 27028 Subdivision Name:
• ,;til '(;' r.l 4=fVi. /-�� Phone#:336-751-8760 ]G�
Section: Lot:
kc+ AUTHORIZATION FOR q
G% �! WASTEWATER Tax Office PIN:# 5��/- L�1!d' -�/ 0 01
SYSTEM CONSTRUCTION
AUTHORIZATION NO: A Road Name G f ��� ��1' " - Zip:
P�
**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
�' j ;% /T�f✓� ~;'' '"`t w - t? IS VALID FOR A PERIOD OF FIVE YEARS.
�"-ENVVnWNMEN1,ADHE ALTH SPECIALIST DATf ISSU D
RESIDENTIAL SPECIFICATION:BUILDING TYPE C #BEDROOMS #BATHS #OCCUPANTS l" GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE { #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE 711Ci_gPE WATER SUPPLY���t 1 DESIGN WASTEWATER FLOW(GPD)4b NEW SITE REPAIR SITE
/� tt i
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�`f ROCK DEPTH 2 LINEAR FT.
_ q I
�� � VT -'cJ. � X_�S , N�7Tr�11-- �.
OTHER 1 -S- !
REQUIRED SITE MODIFICATIONS/CONDITIONS: f�=�TnLL 0-� tri••5TOL7 {� 1k1' IC
IMPROVEMENT PERMIT LAYOUT �--I Ot an I a f TC(7•. Lt"4-5
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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 (336)751-8760.
OPERATION PERMIT l
SYSTEM INSTALLED BY: rii-1 tQl�'
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rJ��tes r �,
AUTHORIZATION NO. r'1 OPERATION PERMIT B 4 1'" 1`DATE 412 v✓
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDD B
ICATE THA E SYSTEM ED ABO E HAS 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.
DOM 02102(Revised)
DAVIE COUNTY HEALTH DEPARTbIENT
(Sfptic Tank) Improvements Permit and Certificate of Completion
r ' (Ground Absorption .Sewage Disposal System - G.S. Chapter 1130-Ayticle 13C)
OWNER OR CONTRACTOR .,,jG0,QJt _ DATE PERMIT.
LOCATION 1<%} ;j^"�jjL %C//llr' M -1906
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME BUSINESS ❑
-� House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS _ NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES '❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES � NO ❑ Four Betl��gmo`se 1000 Gal. j200 Sq.fit.
AUTO. WASH. MACHINE YES C -NO ❑ ! 7
SITE SUITABLE YES E ,-,ISO ❑ � : ?%! �.t; '' ./�/ 1� .- - ;``
SIZE OF TANK l ,
f
NITRIFICATION FIELD ~ sq.,ft. <
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual- ❑.% Publ c
. ;ti?.`•�f-��
100,
IMPROVEMENTS PERMIT BY r '.L�C.- INSTALLED..
CERTIFICATE OF COMPLETION
BY Date /
(8/16/73) *Construction must comply with all o her applicable State and local regulations
LOT AREA
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