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DAVIE COUNTY FALTH /DEPA TME�NTr. SFPTIC,,,TAN*''PER IIT Date -L'- A
Jx'mer/Occupant�%a Ui f- 4, 1 1d #���' C o � To: V4 t/i' (' l5o.�I(i� �i9.`�! a ..
Address AT, N➢k l Address
Building Contractor '541 -ME' Address 4oC
Cal. lc) Manufacturer's Name Address S?P-r, P
No, of lines 3 Width �in. Total length t. No. sq. ft. 200
Type of filter material Total tons used 4'5'
Minimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
600
Two-bedroom house 800
Three-bedroom house 900 900
No one shall install aseptic tank in Davie County without a permit from the Health Offic
or his agent. ,
Date of Final Approval%,2� Signed c C.dn
5a •tarian
I hereby certify that the above septic tank has been installed according to spec'ficatigP.
Signed:
Septi Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.
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' - ( DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
i'emuttee's�''
Name. �. o' _ 4�F�t F. ,�. i�\ � Subdivision Name
Directions to property: Section: Lot: .
IMPROVEMFNT
PERMITTax Office PIN:#
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Road Name: Gl)i 113 Zip: M 0: 7
**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
constraction/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)
S
`\C� \� ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
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 # BATHS # OCCUPANTS 3_ GARBAGE DISPOSAL. Yes o”' No
COMMERCIAL SPECIFICATION, FACB.rr7 TYPE; # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
- LOT SIZE TYPE WATER SUPPLY W 10 i DESIGN WASTEWATER FLOW (GPD.).3G V' NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS:•'TANK SIZE - GAL. PUMP TANK GAL. TRENCH WIDTH 3 F ROCK DEPTH 1 ' LINEAR F d 0 d
OTHER
i
REQUIRED SITE MODIFICATIONS/CONDITIONS: -
RAPROVEMENT PERMIT LAYOUT ` - - �•
douse
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**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 (704) 634-8760. -
i n i
AUTHORIZATION NO,. OPERATION PERMIT BY: DATE: -
**THE ISSUANCE O WHYS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 O� G.$. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAYBETAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME: -
DCHD 05/96 (Revised)
' R x DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION —
Vermit4e,s p�
":Name:¢ i.`t�,VrV,%,lz %( epi) Subdivision Name:
Directions to property: "��11� '. '�c'S� Section: Lot: �1
EUPROVENTNT
PERMIT
Tax Office PIN:#
1 .. Lk t aY
**NOTE** This Improvement Permit DOES N&fluthorize the construction or3i UIation of a septic tank system or any wastewater system. An
AUT IORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constmetionlmstallation of a system or the issuance of a building pemrit.
(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
\ ): -� a 5 1 r•y.. 1 ,` j ± PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICPRTION: BUILDING TYPE # BEDROOMS _�:5 # BATHS I # OCCUPANTS A� GARBAGE DISPOSAL: Yes 01
0
COMMERCIAL. SPECIFICATION:, FACILITY TYPE # PEOPLE # PEOPLF/SHEFT # SEATS INDUSTRIAL, WASTE: Yes"or No
LOT SIZE TYPE WATER SUPPLY W DESIGN WASTEWATER FLOW (GPD) JG V NEW SITE.—REPAIR SITE 4
I
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH r�r LINEAR FT. la
rrrf4pR -
: REQUIRED SITE MODIFICATIONS/C
.- IMPROVEMENT PERMIT LAYOUT
. �t6
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•1,
Joe To
F
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01� f
^I °. n
9**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 TIRDAY OF INSTALLATION. TELEPHONE # IS (704) 6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
i
**THEISSUANCE
a` 7
OPERATION PERMIT BY: DATE:
)N PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
130A, SECTION ,1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN ASA
LL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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y
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9**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 TIRDAY OF INSTALLATION. TELEPHONE # IS (704) 6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
i
**THEISSUANCE
a` 7
OPERATION PERMIT BY: DATE:
)N PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
130A, SECTION ,1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN ASA
LL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
r
" - DAVI`E--COUNTY HEALTH. DDEPARTMENN�T'. -.. SEPT`ICC TANK PERRMMIT Date / AAe
-- / P IIA-Ui lJ•t r'`/Y+;,W-q `-O_ ..lav:-=T",T .'{;� "'''Vi ('� - /IfiC c7 i%/K lai .--
Jwner Occu accnf�t e�
Address � fib' /k`%c /ff ,�% � - Address A., 7—PF IK
Building, Contractor 5061"P Address %�%C S v.'//P
Cal. _ Manufacturer's Name ��v� (' % 9-W Address P77, P
No. of lines 3 Width �in. Total length o702 S ft. No. sq. ft. o
Type of filter material -f-/n /c�Total tons used s
Minimum REquirements: House Trailer Tank cap. 800 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 Offic
or his agent.
Date of Final Approval (� signed: c
Sa tarian
I hereby certify that the above septic tank has been installed according too spec'fication
Signed:
Septic Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME L,�aYbAYa %Yllisd� PHONE NUMBER Y7�� r�� �
ADDRESS a�� /� %�Si/lrlh `l (N SUBDIVISION NAME AdI I /P-)4
DATE SYSTEM INSTALLENAME SYSTEM INSTALLED UNDER an, ?
TYPE FACILITY NUMBER BED OOMS NUMBER /PS�E%%OPLE SERVED/ �/
TYPE WATER SUPPLY �u.rry lla� 8' IFY PROBLEM OCCURRING Ale- CT7rt�</CL2 .
DATE INEQUESTED 77-/7'- / / INFORMATION TAKEN BY
This is to certify that the Information provided is oomect to the best of my knowledge, and that I unde"nd I am responsible for all chargee Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT.
Rev. 1193
'G"(r. a:•.. y.o., ¢a?-'ry r.:� y.tMr,�aTni-..y ••.y0'a'..y„r +•n 9: ". i. �.�.vy ry :Y?it`>iY!" fn .�m,.,r.....,.g. r�-'� p lw •V_>^;.
A1"ORIZATION-WOr Q 7 8 3 DAVIE COUNTY HEALTH DEPARTMENT
+? Environmental Health Section " PROPERTY INFORMATION
r
Permittees \\ \\ P O: Box 848
Name i'Q%Vy h _ ARliYaRt� \I\i�50� . Mocksville,'NC 27028 Subdivision Name:.
Phone #: 704=634-8766
Directions to propeRy: Ips` —� os Section: ' -i— Lot :L V
AUTHORIZATION FOR
WASTEWATER .. ..
fice PIN:#
SYSTEM CONSTRUCTION
Tax Of
Sz�a ��� Road Name: �a UJ Zip: 0i
**NOTE** This AuthorUtion for.Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits: This Form/Aathorization Number should be presented to the Davie County Building inspections
Office when applying for Building Perunts y:
(In compliance with Article 11 of G.S . Chapter 130A Wastewater Systems,
p � Section :1900 Sewage Treatment and Disposal Systems)
v w i ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONS
TRU "ION
/ IS VALID FOR A PERIOD OF FIVE YEARS 't9
.,.. ,
ENVIl20NMENTAL HEALTH SPECIALIST : DATE ISSUED