143 Center Circle Lot 157 },y 4 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
%.Peftittee
Name:"'f•'-. F' Subdivision Name:C71
jf
Directions to property' ° J —' l Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
y✓� : a r ;' �. Road Name:!""
ame: ZiD:.%
d
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An II
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 SPECIALIST • DATENSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE/ =F # BEDROOMS _�— # BATHS # OCCUPANTS . GARBAGE DISPOSAL: Yes ok$
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLIaSHIFT # SEATS _ INDUSTRIAL WASTE: Yes or No
LOT SIZE -1,-r TYPE WATER SUPPL f. T ` DESIGN WASTEWATER FLOW GPD) NEW SITE PAIR SM�.
SYSTEM SPECIFICATIONS: TANK SIZO!FG t. PUMP TANK GAL, TRENCH WIDTH ��` / I ROCK DEPTH ;; LINEAR FT.�`'I ,
OTHER ,/ // e'. r,r (i, �r,.:/� t:i.l� //i;r %/V
IMPROVEMENT PERMIT LAYOUT""�'"
Dot
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"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPE9'M %Tffl7§ SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE fh95 . 'f -S h0
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 I1 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 05N6 (Revised)
1<'
no
DAVIE COUNTY HEALTH DEPARTMENT
No of -Bedrooms
This permit is granted to 2
at the residence of
Building Contractorlii
Septic Tank Specifications:
Manufacturer's Name
the
ass
CZ� Addr'ess
Lvi
SEPTIC TANK PERMIT `/ l
Date
Length Width Depth Capacity_ Gal. FeO
i-
/
No of lines,_L widthTotal Length ��ft. No. of S . Ft.� 0 0 a
Type of '-filter material O Total tons usedC *---
Minimum Requirements: House Trailer Tank Cap. B00 Sq. ft': line 400
Two-bedroom house 800 600
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. n
Date of final approval ._� —a 3 ! Z Signed:
anitarian
I hereby certify that the above septic tank has been ins alled according -to
specifications.
Signed: /S � 7s�
Septic Tank Contractor
i
Note: Make sketch of disposal systom on back of'sheet and mail to Health Center,
Mocksville.
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APPIJCATION FOR SITE EVALUATION VEMFM PERMIT & � LS'�C� E J ppipp
Davie County Healthh Department
EnvirotlmentaiHealth SectI011 r
P.O- Box Mock vi/ leo NCHosP tal 27 28 Street FR 1 3 2002
(336)751-0760
***IMPORTANT***,THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE-1.M*0=AZW
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
Name to be Billed
- Contact Person
-
In 0,0 t�' 1,
Nailing Address I1�
Home Phone
��^I��7�/�
1r
,�/
I
r}
City/State/ZIP V l [��,1� ,�y i P,; 1 V
C, / 1 C )7 'P{ Business Phone
2.
Name on Permit/ATC�+if Different than Above
Nailing Address -_y, )a.l�
City/State/Zip
.3.
Application -For: ❑ Site Evaluation_
Improvement Permit/ATC
❑ Both
a.
system to service: i House ❑ Mobile
Home ❑ Business ❑ Industry
❑ Other
S.
If Residence: -# People 115 _.
# Bedrooms #
Bathrooms —
❑ Dishwasher ❑ Garbage Disposal �o„Washing Machine ❑ Basement/Plumbing
/type
❑ Basement/No Plumbing
6.
If Business/Industry/Other: Specify
# People
# Sinks
.# Commodes # Showers
# Urinals # Water Coolers
'IF FOODSERVICE: # Seats
Estimated Water Usage (gallons
per day)
7._
Type of Water supply: ❑ County/City ❑ Well
Community
B. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Po
If yes, what type?
"*IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMIT7•ED by the client with THIS APPLICATION.
Property Dimensions: _� i��,�1 WRITE DIRECTIONS (from Mocks'v1ille) to PROPERTY:
Tax Office PIN: # 5112155 0 7 ` 0, (' I`'i' ` {a�Y��n_n,,IS 4d �I
Property Address: Road Name l .pn r l , (ilv, ` w l -bad or� K+
City/zip M0rkS\/i tP , Ju l nd J5+, m-% P-eaI-er Pe
If in a Subdivision provide information, as follows: n 1�S b Vl C7 I
Name..
Section: Block: Lot: Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsiSed or changed. I, also, understand that I am responsible for all charges incurred from ,
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitabili
DATE Z- 13 ` b2- SIGNATURE JVJA
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Inclu e 1 of t ollowing: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations)
Site Revisit Charge
b wSN '-- /Date(s):
n � Client Notification Date:
Fre...EHS:
Account No.
Revised DCHD (07/99) Invoice No.
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
/ APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
,kPHONE NUMBE
//��
e �[ 1p�Le. SUBDIVISION NAME . e'z" Ric
LOT # 1 5
DIRECTIONS TO
DATE SYSTEM INSTALLED -7:>-- NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS �3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the Informalion provided is correct to the beet of my knowledge, and that I understand 1 am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1193
E-2