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149 Whitehead Road Lot 9 Section 2Mqi '>r� r. Kr-�.. u....w�+...i w• J'Si_ i' • - _� .- � -� .. � _ .. .,- .... .. . .d ... 666 •N �' •� �- rdAVIF,_CiOUMrVHI�Ar 'H DE14RTNE?'� - IMPROV)�MENT AND OPERATION PERMITS PROPERTY INFORMATION Pere',. t, Name: 'Z) f' . i ,* fi t�� f rir` Subdivision Name:eAlWoocl1 Directions to property:,, ri /�' Section:__ Lot: IMPROVEMENT PERIGIIT Tax Office PIN:# 144,5p Road e: eQ �iP:�C a06 **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 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 SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALISTA I SUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. I RESIDENTIAL SPECIFICATION: BUILDING TYPE _�� # BEDROOMS_ �'� # BATHS -.2,- `# OCCUPANTS S� GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) 0 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ?C' ROCK DEPTH -7 -V LINEAR FT. c��Jd / REQUIRED SITE MODIFICA "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 SYSTEM INSTALLED BY: am &YA A 4/v b� 15� AUTHORIZATION NO. OPERATION 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. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) Cc3�G� NAME J Lr N d lY/ I b�,r� PHONE NUMBER, ADDRESS I'7 SUBDIVISION NAME (rreeAJ1066d ZO n IiaffoP. /Vii, a1 QQ to LOT # q DIRECTIONS TO SITE _ l � IeO `�161 /e ) S&db/a "f" fAJ IeN dnderlms-� d 7-t-wi ki(i N Whi aval DATE SYSTEM INSTALLED 7 NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE /nSERVED 1 TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING P44/ riu lid l iNe of se>afic� s fo1 DATE REQUESTED /-5 049 INFORMATION TAKEN BY ��'/1L 44-i 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. 1193 /W a 11Rn 2G -F, & vs- .r§? ? a c io3 •, .j v:.: i: _. .. .i snNi.h: .;..a s�.i�,a � a i ..4:I _ .. i � .a .. d.i ... .. ! AUTHORIZATIO14 NO: V 175- Q DAVIE COUNTY HEALTH DEPARTMENT V Environmental Health Section PROPERTY INFORMATION PermAttee's• t / P.O. Box 848 Name. l� �4 �i1� [� . / Mocksville, NC 27028 Subdivision Name:��e/YWi10%9[ Directions to property: f Gaf: ! f Il%�. A-4 I., Phone # 336-751-8760 Section:-�� Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION — R �d`Na� : ea-�i/ed7006 **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 G �� f�� ✓r . Q IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SP CIALIST DA E ISSUED r ».q r... -A; 114 1750' .:DAVIE.UNTY HEALTH, DEPS p4ENT ' ` IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pergltteki` Name: ° Subdivision Name: Directions to property: r: " Section: Lot: IMPROVEMENT PERK" Tax Office PIN:# Rb/Name: _ Zip: yQ d **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 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 SITE g PLANS OR THE INTENDED USE CHANGE YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST dATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS 7 # BATHS -,9# OCCUPANTS S GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY% fJ _ DESIGN WASTEWATER FLOW (GPD) _,."?G U NEW SITE REPAIR SITE Y SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK l )GAL. TRENCH WIDTH f ROCK DEPTH y 'LINEAR FT. ;� ,5% / OTHER "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. 4 OPERATION PERMIT 0 SYSTEM INSTALLED BY:la- 121/yy12 AUTHORIZATION NO. -, . OPERATION PERMIT BY: a + DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS �EEN 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 05/96 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT q`L NAME Alkazqf / 7� PHONE NUMBER 9Y16 /7 4 I ADDRESS /* 2l L-��� Tct. SUBDIVISION NAME SUBDIVISION LOT # IgI'L °-t DATE SYSTEM INSTALLED • �h-,. 79 NAME SYSTEM INSTALLED UNDER /' SPECIFY PROBLEMS OCCURRING S back -5- 74P .� - v DATE REQUESTED �� �'-! IN RMATION�EN BY `r I to ` DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage Systems Permit rNumber Name 1�2'1'_d �,�" A%: f.; ""^'I. 1'JL � Date "' /"_ �� N2 2 i Location Subdivision Name f ©�F'�`��-'- �?r -�`�{ Lot No. Sec. or Block No. Lot Size House'! Mobile Home __ Business __ Speculation No. Bedrooms No. Baths a No. in Family _ Garbage Disposal YES ❑ NO p' Specifications for System: Auto Dish Washer YES E] NO ❑ Auto Wash Ma;hine YES p NO ❑ �C�U�1,�/�1� Type Water Supply (76 __— *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. 1/ /Vt, t0 / I'vo(A Improvements permit by -��/1 *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 day of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by u 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. n - DAME COUNTY HEALTH DEPARTMENT ` a IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Name �' �, ,��,' % ��' r='� �`- �;� °;Z Date ";��' �_ � p Location Subdivision Name Lot No'% Sec. or Block No.J Lot Size House c' Mobile Home _ Business __ Speculation No. Bedrooms No. Baths — No. in Family Garbage Disposal YES ❑ NO ❑ ' Specifications for System:._ Auto Dish Washer YES p NO ❑ Auto Wash Ma,hine YES U NO ❑ %'(% I�r%i� J-� Type Water Supply �,r __— *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. I Improvements permit by *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 day of completion. Telephone Number 704-634-5985. Final Installation Diagrams �-�" `�� System'V 1119 V Irk t I Certificate of Completion fT� �� 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. ' DAVIE COUNTY HEALTH DEPARTMENT P. 0. BOX 57 c �� MOCKSVILLE, N. C. 27028 (7 04) 634-5985 Statement for Septic Tank Improvement Permits and/or Site Evaluations NAME % y DATE ISSUED z ADDRESS PERMIT NO. Explanation of charge -- i AMOUNT DUE SANITARIAN PLEASE REMIT THE ABOVE AMOUNT ON RECEIP.�OF THIS STA�Er4ENT.