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300 Dogwood LaneAUTHORIZATION NO! 60, A, DAVIE COUNTY HEAIJTH DEPARTMENT � w 4-5 Environmental Health Section PROPERTY INFORMATION Permittee's i P.O. Box 848 Name:1rLI 2� � Mocksville, NC 27028 Subdivision Name: C")t-0 L -A rJ Phone # 336-751-8760 Directions to property: Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# Road Name: Zip., **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 JArticle I7 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 4O -HEALTH SPECIALIST r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION -i-7c7r IS VALID FOR A PERIOD OF FIVE YEARS. TE ISSUED " 6y_ _ laF- !Y l+Y...�F•., `7— '7 rM1^^^,i.f esN.✓�1.}Yp.Kira.�,ii+."C.J.'--'.-•r"/"i .r; ^.1L•. ' .%V-n.i``in„......�.-c-�-.+.y_.},-v V,YViIYv,y`Y'� • 1. ' DAVIE COUNTYREAeTI�DEPARTMENT sl, ROVEMENT-AND OPERATION PERMITS' PROPERTY INFORMATION ermittee's =�{ ,'i ..: 14 4 !' " Subdivision Name: � 7.; ~Drections`, to property; �'.` 1 'f' �1 Section: Lot: IMPROVEMENT rt✓,cao. -y CrXD. PERMIT •; . Tait Office PIN:# a Road Name: Zip: **NOTE** This`Improyement Permit DOES NOT.au&rize the construction.oi installatidn of aseptic tank system or any wastewater system An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Departmen(prior to the : construction!installation. of a system or the issuance of a building permit. (In compliance with 'cle E `l of G.S. Chapter 130A, Wastewater Systerris, Section .1900 Sewage Treatment and DisposalSystems) _ **#NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER' *FT�iviRO fu" iti I AL HEAI, fH PECIAL7ST D `rB ISSUED . SYSTEM CONTRACTOR MUST SEE THLS PERMIT BEFORE 4. INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE M # BEDROOMS .3 # BATHS # OCCUPANTS Z GARBAGE DISPOSAL. Yes r No COMMERCIAL-SPECIFICATION:.FACILrrY TYPE �# PEOPLE # PEOPLEISHIFI• # SEATS INDUSTRIAL WASTE: Yes or No LOTSIZE TYPE•WATER SUPPLY, o DESIGN WASTEWATER FLOW (GPD), > NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: -TANK SIZE _GAL. 2PUMP TANK �G/A�L. TRENCH WIDTH Sim ROCK DEPTH �Z LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: [Amu_ 9_1� cel l od IMPROVEMENT PERMITLAYOUTRpVED EFFLtE+1T.F.�LTER �*R17SE�R(S)j�IF69'1 7BEbd FINISHED GRADE IGGpome4o, 0 POP **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 ',OPERATION-PERMTT • - ems' x3b x iB. r st;�A.s AUTHORIZATION NO. -- U OPERATION PERMIT BY t i ATE: 3 p J **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCZ40VE HAS-BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER `130A, SECTION .1900 "SEWAGE TREATMENTAND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY.FOR ANY GIVEN•PERIOD OF TIME. **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) " ***XTn1rTr1 *** TLi7C! nT. nAxpr ie VT ro TL`AT T , 0. , �, Y .... ...,u..a av a.ay.vv�.aay. ac •aaau PLANS OR THE IlVTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE e INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE i l # BEDROOMS # BATHS # OCCUPANTS ' GARBAGE DISPOSAL: Yes,6r N0 . COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE:,Yes or No LOT SIZE TYPE WATER SUPPLY' DESIGN WASTEWATER FLOW (GPD) G NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 361 1' ROCK DEPTH __LINEAR FT. IOU , OTHER 1 j ._`j �- f 'U I I CA X REQUIRED SITE MODIFICATIONS/CONDITIONS: �J � C L ©^1 CkTN (Z IMPROVEMENT PERMITLAYOUTK-fj13jPk0VED EFFLUENT Il_TE1t* *PUSEP(S) IF 611 B LOt) FIHISHED GEADE-K � ` —�i -•`� r--1 i -Vj 1 U 0'y' , to X 17 't --7r-4) 4) ..a **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR F)NAL INSPECTION 9F, pSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # Isj)` 9-$ t336} ..1— 7&C OPERATION PERMIT 1�STEP�T�"-S'f w o. .. . . .................. .... ..... . .. ..... AUTHORIZATION NO. f)(0 "1 OPERATION PERMIT BY: a DATE: �� G v U **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED BOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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) COUNTY HEALTH DEPARTMENT 41. ,DAVIE —IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittees Name: 1 F ; _ { �" Subdivision Name: r Directions to property: ! l ' E ) Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# `r . j f Road+Name , r 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) " ***XTn1rTr1 *** TLi7C! nT. nAxpr ie VT ro TL`AT T , 0. , �, Y .... ...,u..a av a.ay.vv�.aay. ac •aaau PLANS OR THE IlVTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE e INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE i l # BEDROOMS # BATHS # OCCUPANTS ' GARBAGE DISPOSAL: Yes,6r N0 . COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE:,Yes or No LOT SIZE TYPE WATER SUPPLY' DESIGN WASTEWATER FLOW (GPD) G NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 361 1' ROCK DEPTH __LINEAR FT. IOU , OTHER 1 j ._`j �- f 'U I I CA X REQUIRED SITE MODIFICATIONS/CONDITIONS: �J � C L ©^1 CkTN (Z IMPROVEMENT PERMITLAYOUTK-fj13jPk0VED EFFLUENT Il_TE1t* *PUSEP(S) IF 611 B LOt) FIHISHED GEADE-K � ` —�i -•`� r--1 i -Vj 1 U 0'y' , to X 17 't --7r-4) 4) ..a **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR F)NAL INSPECTION 9F, pSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # Isj)` 9-$ t336} ..1— 7&C OPERATION PERMIT 1�STEP�T�"-S'f w o. .. . . .................. .... ..... . .. ..... AUTHORIZATION NO. f)(0 "1 OPERATION PERMIT BY: a DATE: �� G v U **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED BOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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) 'Y', - w.P•� i f N ,f�' j c u �' =; to . t a:, t 1 n » !' 'a' 4 f. r # a 'i ✓XlJ 11 1 M d h �l DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT ANDCERTIFICATE OF COMPLETION •NOTE: Issued in Compliance With Article II of G.S. Chapter 130a en : Sanitary Sewage Systems t' , ,r q, ' - Permit Number a Name"r� /° r ��-'l ✓ r ;,X %'"/ f LDate ND 7879 Location x Subdivision Name 1. f .1: r�,) i j / i ` ' '' �- _ � � Lot No. Sec. or Block No. aLot'Sze n House Mobile Home _ Business __ Industry; No.Bedrooms - . No. Bath o. i Baths N n Family _. Public Assembly Other Garbage Disposal ; YES E3 - NO [ '- 'v,is SpecificationsIQS Sy m: •Auto Dish Washer YES NO p 4� al -,-,'Auto `Wash Ma^fine YES NO Q " i, Type,Vater Water Supply 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 �6 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM',"4 h ,� bra jI{1 .';{ ,. a 0� Gp - �I V��i • r S I: - ' J v $ �4 S1//✓��j�'�L'/ Ile • gyp.. � ,b ti` 'T}•J. I��f �i 4.(+1. ' (r-. t -.... t .. :. "d` e `r- fi y`�-b��3T,,,P�¢�tt�a' •� �� .I�!'- �tiyl 0 t i. • �f � . , ,. _ - �1 t } $fi-::�atY,.. 1'* k, R• K iE. 4 6.p4 bo ��1 �r � c � - ; E i•. u t.r��.. ,rem a Q" S `ty'•�7 L xb� Vim+ �. ��' YC' �1�. � � 4F�, S Y� y�'�� ��'„ N !. •'t , � _ µ }i .A r f4.. n�, %[ 4.p �` f �[5'S fn 2'4-tr'�'.. 1y,� +� 1 a ; .`. n .. � ,. :. ,. .• ., - v ,. 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., 1:00 1:30 P.M. or 4:30-:5:00 P.M. on day of completion. Telephone Number: 704.634.5985. Final Installation Dia r '' f 9 a /L Q t i System Installed by ti 9 i 9m,�,��^rl/V/,7 7 EIY1C s < n [ U° - } z a{ i. `Certificate of Completion_ Date �Y f _ '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 Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTIOQN ❑ Name:/ .2<L �fi% / ",��Or� Phone Number: �/ (Home) Mailing Detailed Directions To Site: G/l� -- c.v Property Please Fill In The Following Information About The Existing Dwelling- Name welling Name System Installed Under: C� �����/ �05Type Of Dwelling: �4eL� Date System Installed(Month/Day/Year): Number Of Bedrooms: o Number Of People: 2 Is The Dwelling Currently Vacant? Yes ❑ No W- It Yes, For How Long? Any Known Problems? Yes ❑ No 9-'Iff—Yes, Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: �G� Number Of Bedrooms: . ? Number Of People: az Requested By:. (Signature) For Environmental Health Office Use Only Approved ❑ Disaapprovre-dt ❑ C'nmmAntc• � \� I � 1� 1� 'moi 1 � ��""" � � Requested: Environmental Health Specialist � Date / _17-7JCy *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: Paid By: Received By: Account #: L Invoice #: ,� ��