1797 Underpass Road Lots 4-5 Section 2-\' leyY ..4 i�. 1^'JS Vie, .♦ r ..'Y.csP y`. -c ,. i � .i . I..,r c ,....r . .. , i c fr � .�^'. l.,
,,UTHGRIZATION NO: ' '675A DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee' --'l / P.O. Box 848
Name: / // r`' _ L.` -�� Mocksville, NC 27028 Subdivision Name:^
hone # 336-751-8760 --
Directions to property: i�%r ,1 ''i/e, P Section: ?sr3" 't' • Lot:
,C? AUTHORIZATION FOR
WASTEWATER
Sc7 5 Tax Office PIN:# -
SYSTEM CONSTRUCTION
�j Zip:
Road
i ame:
"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 .1900Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
rpt, c _ Yi t IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
`'' `� DAVIE COUNTY HEALTH'DEPARTMENT
r _ 1 A
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Petmittre's
Name:- ./-�J - �; SubdivisionName:
Direct'- to � `� � � f ' Section: Lot:
IMPROVEMENT
PERMIT Tax Of//firrc77e99PIN:# - -
�. Road Name . �f�1T l , fifi Zip:
**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 IIVTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
i
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYO 9 r u k - nn c.
I� Z
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPEG0I=0R WHIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE fjSGqq5j4.43q%C
OPERATION PERMIT r o' Z
} SYSTEM INSTALLED BY: ji
W,
' x
1
AUTHORIZATION N0.(7L----OPERATION-PERMFF-&yt=-_---DATE
1
"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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
x,rw.. a
V DAVIE COUNTI' HEALT-W-DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PRS
Y�Pertnit e'" , " i
Vj
Subdivision N
k,;Directions{to'property Section: =
„ReoCa a . y. �c.:x :rte v �,: �- 4 �•_,�g `v��
RTY.INFORMATION
t ., Lot: �f.,:
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME ��G�e}//moi `` Y PHONE NUMBER
ADDRESS ����Yt'c'i� SUBDIVISION NAME
V 0 4OX 3`%% //GOCf�.idir�C /�i� .2-%U.� LOT # J
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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
P///t/ '�k 7 ryp e' Ff-00 063 Acf # 0 63 �V � ////
�► Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.***
�'pit �� DATE 1 " �-�' �.� AUTHORIZATION NUMBER
NAME
�� j b
WE ON IMPROVEMENT P(E�RMIT (If different than above)
SITE LOCATION o e *� �' "" V ("V,Q°S — ! 797 7e-;, d�pA.00 'KPL
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
}*+NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SY�TEM CONSTRUCTION IS -VALID FOR R PERIOD OF -FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE
DCHD 10/95
IMPROVEMENT PERMIT
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
**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)
NAME � ��`2 PROPERTY ADDRESS 1 y N eQR �c� DATE I ID -a4 -7.6
v �\v4 c a, N j O
LOCATION�'� QQ to W o h'P�T2s
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: YesQ
COMMERCIAL SPECIFICATION: FACILITY(TYPE # PEOPLE # PEOPLE/SHIFT '#,SEATS INDUSTRIAL WASTE: Ye#INo
C1Y'.:
LOT SIZE or�.ca TYPE WATER, SUPPLY DESIGN WASTEWATER FLOW (GPD)"_ 60 NEW SI;kRE`,' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 1000 GAL: - .PUMP TAMC GAL. TRENCH WIDTH 3' ROCK DEPTH J 2 r LINEAR FT.
OTHER y
' a
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT Ii -.SUBJECT TO REVOCATION IF SITE PLANS�OR THE INTENDED USE CHANGE. YOUR,&TERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
C.) U S �
'1
Ioo� "J
l our
{, IMPROVEMENT PERMIT BY
**CONTACT,A REPRESENTATIVE OF THE DAV IE COUNTY.HEALTH DEPARTTi6G FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A. M, OR I:W4t3@� P.M. ON THE DAY OF INSTALLATION:'TELEPHONE # IS (704) 634-9760.
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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCH, 10/95
N
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
iiNOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewate
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)
NAME �> \ ``� .4 PROPERTY ADDRESS C =: 1` DATE b .-J1
LOCATION
SUBDIVISION NAME .\ ��, t�,t_\� LOT NUMBER SEC./BLOCK NUMBER -^
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS �.' # BATHS '3 # OCCUPANTS GARBAGE DISPOSAL: Yesf'�
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY '.,. DESIGN WASTEWATER FLOW (GRD)' NEW SITE,.. REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 2!. GAL. PUMP TANK GAL. TRENCH WIDTH :�� ROCK DEPTH 1 � LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS.SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
fJ GJ �
<
IMPROVEMENT 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:N-1;30 P.M. ON THE DAY OF INSTALLATION.' TELEPHONE # IS 1704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY
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 ASA
GUARANTEE THAT THE SYSTEM WILLFFLNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF AIME.
4
t.-"DCHD 10/95