135 Center Circle Lot 14Pennittee's 6 ` DAVIE COUNTY HEALTH DEPARTMENT
Ngme: )` t (rt S 6, VX Environmental Health Section PROPERTY INFORMATION
// P.O. Box 848
Directions toofpropertty: [ r� I i� Mocksville, NC 27028. Subdivision Name:
S 1 ± L /l� /� fyl' w Phone #: 336-751-8760 / (/
J Section: Lo[: /
AUTHORIZATION FOR C
lo •� _ �,_, _ WASTEWATER Tax Office PIN*
SYSTEM CONSTRUCTION
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AUTHORIZATION NO: 002997 A 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 Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
6 U IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALT SPECIALIST DATE ISSUED �1
RESIDENTIAL SPECIFICATION: BUILDING TYPE F # BEDROOMS -3-- # BATHS eL # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYP/E# PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
e4 .LOT SIZE 0. L' a- TYPE WATER SUPPLY W - DESIGN WASTEWATER FLOW (GPD) ��Q NEW SITE REPAIR SITE
Y
f SYSTEM SPECIFICATIONS: TANK SIZE /---GAL. PUMP UMPTA TANK GAL. TRENCH WIDTH ROCK DEPTHA/^L[NEAR FT.
;a OTHER O 5 404"X.
---REQUIRED SITE MODIFIGATIONS/CONDITIONS;
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IMPROVEMENT PERMIT LAYOUT:,',r,
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751.8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
i
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 NOWAY BE TAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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Permittt�ee's^
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ti' DAVIE COUNTY HEALTH DEPARTMENT
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-----
Environmental Health Section PROPERTY INFORMATION
I P.O. Box 848
.Directions to property: ! �(J Mocksville, NC 27028 Subdivision Name:'
C ff / / Phone #: 336+751-8760 1f L/ �% ( `/ b P 1 e Section: I Lot:
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AU WASTEWATTER ORIZATION OR 5 � t �� '7 �) . 6
{ (I 1 SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 002997 A 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 Forn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER i
G ,`J IS VALID FOR A PERIOD OF FIVE YEARS..
DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 5 r # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or Ho
IMPROVEMENT PERMIT LAYOUT. •�+;.,,
COMMERCIAL SPECIFICATION: FACILITY TYPE
# PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY
3t/y
- 09
SYSTEM SPECIFICATIONS: TANK SIZE GAL.
DESIGN WASTEWATER FLOW (GPD) NEW
PUMP TANK GAL. TRENCH WIDTH V
SITE REPAIR SITE
ROCK DEPTH *LINEAR FT.
OTHER ,
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT. •�+;.,,
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.II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. II
OPERATION PERMIT II
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 AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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DAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PERMIT
No of Bedrooms 1?_ Date 3 —/— / at,
This permit is granted to r for the installation of a septic tank
at the residence of// Address r^
Building Contractor ,„p 131elo c Address
Septic Tank Specifications: Length_ Width Depth Ca aclly
Gal.
Manufacturer's Name D �i`Address�,fM=acs
No of lines_ width�in. Total Length _�aSf`t. No. of Sq. Ft. D�—F ,17 PI�i jt'S
Type of filter material �[D pro / Total tons�used
Minimum Requirements: HouseTrailer ` Tank Cap. $00 ,Sq. ft. line 400
Two-bedroom house :��80Q 60o
Three=bedroom house 900` 900
No one shall install a septic tank in..Davie County without--a-permit:from the Health
Officer or his agent. o l j
Date of final approval Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to
specifications.
Signed*�3rrf/
Septic Tank Contractor'.
Note: Make sketch of disposal system on back of sheet and mail to Health Center,
Mocksville.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION q V G `�
AP/PLICATION FOR IMPROVEMENT PERMIT (REPAIR)
Jd 4 N e �j A-% PHONE NUMBER
ADDRESS ( Cir SUBDIVISION
DIRECTIONS TO
C"
LOT # I �/
Wo v4e
DATE SYSTEM INSTALLED -70"NAME SYSTEM INSTALLED UNDER S hrJ
TYPE FACILITY NUMBER BEDROOMS -3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY L/! y SPECIFY PROBLEM OCCURRING
DATE REQUESTED y �d INFORMATION TAKEN BY !L/./Wr Lk -5
This is to artily that the Information provided is correct to the best of my knowledge, and that I understand I em responsible for all chargee Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
liev. 1193
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http://maps.co.davie.nc.us/GoMaps/map/mapframe.cftn?CFID=61079&CFTOKEN=5009... 12/14/2009