203 Raintree Road Lot 12)permittee s DAVIE COUNTY HEALTH DEPARTMENT
NamB: 1. x��` t/e` - Environmental Health Section
P.O. Box 848
Directions to prollertyt �"� ` ' ��r' 4�� Mocksville; NC 27028
Phone #: 336-751-8760
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002637 A
PROPERTY INFORMATIOI V46�
Subdivision Name: ` `r-
Section: Lot:
Tax Office PIN:#ff
Road Name: -If ji- %i; .�? 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 I 1 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
AL HEALTH SPECIALIST DATE ISSUED
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
LOT SIZE TYPE WA'TER'SUPPLY: C - DESIGN WASTEWATER FLOW (GPD) a /NEW SITE REPAIR SITE Com'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK
// r/
DTH - ROCK DEPTH f ' 4 LINEAR F ��
4
REQUIRED SITE MODIFICATIONS%COND�TION$. 1i
r
IMPROVEMENT PERMIT LAYOUT y
" l
r
s�
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 ✓510
SYSTEM INSTALLED BY: q
f�
G
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.
ocfioovoz (Revised) i�ee-l. /(N�/.� 5
permittee s ! `a DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to prod rty ._''; , ` ' r Mocksville; NC 27028 Subdivision Name: !'j• '
Phone #: 336-751-8760 f �',•
Section: % Lot: ! ��
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
A � •� _�.-�i s i`+S � r' �•` �� ,.V i! s^ -...
AUTHORIZATION NO: U U Z - V O/ ti Road Name: Zip:.-=��? t
**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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: B61LDING TYPE * # BEDROOMS # BATHS __ # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
J
LOT SIZE TYPE WAYER SUPPLY C' (2 DESIGN WASTEWATER FLOW (GPD)' _-7/,_,'NEW SITE REPAIR SITE t----
..4
/ /
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL./ TRENCH WIDTH ---T- 6� ROCK DEPTH LINEAR F rjf
OTHER [.: / +i t
REQUIRED SITE MODIFICATIONS/CONDITIONS.
J ,
IMPROVEMENT PERMIT LAYOUT
42,
Kit,0 ,^
/rpt.
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.
I OPERATION PERMIT
i
SYSTEM INSTALLED BY:
^� AUTHORIZATION NO. OPERATION PERMIT BY: hp r DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 02/02 (Revised) Pe
A 0f 0 -TAI 5706
p
0�
y. DAME COUNTY HEALTH DEPARTMENPAiAl_fre-
f ..,
'. (Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorptio_n,Sewage ]Disposal System.- G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR ..Ip` J 1. 5 1 DATE I bo PERMIT
.t.•t ��rr
- LOCATION ,:� %. , n.'.i� .''�•'. C.. Fi:'.
N
4'+��_,r..,. e'Z+d..l yr ,±� >.i,;r. ,� �\ •
1645
S.R. NO.
SUBDIVISION NAME%� :4' + �t`t
An
1 LOT N0. SECTION . OR BLOCK N0.
HOUSE MOBILE HOME E3
BUSINESS ❑
BEDROOMS_ N0. BATHROOMS ?i
House Trailer 800 Gal. 400
Sq. Ft.
NO. .
/
Two Bedroom House 800 Gal. 600
Sq. Ft:
GARBAGE DISPOSAL UNIT YES
NO ❑ '
Three Bedroom House 900 Gal., 900
Sq.` Ft.'
AUTO.*DISHWASHER. -YES
NO ❑
Four Bedroom House 1000 Gal. 1200
Sq. Ft.
AUTO. WASH. MACHINE YES
SITE • SUITABLE YES
NO 13
° NO ❑%�
O1V 1
SIZE OF TANK gal.
'ft..
f
R
NITRIFICATION FIELD
sq.
X X
.DEPTH `OF' 'STONE IN LINES i
'
t!>c-INTI. �"
?
. • .
WATER SUPPLY: °Individual 13Publie
❑
IMPROVEMENTS PERMIT:BY
'INSTALLED BY L..
` DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) Gam'
NAME ���% G'GS PHONE NUMBER
ADDRESS �!� ��` SUBDIVISION NAME iti 1/Go
/' �%'1/i'9�✓L°Y LOT # /,.2
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED 97 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, andAt I ynderstap9 I, fm responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT -&/, C)
Fiev.1/93 —/ 4 /66,�?-2/
DAVIE COUNTY HEALTH DEPARTMENT
�3
(Septic Tank) Improvements Permit and Certificate of Completion r
.(Ground Absorption Sewage Disposal System -' G._S: Chapter 130 -Article l3C)
OWNER OR CONTRACTOR - S ] 5 'e. ! DATE I / f� % PERMIT
LOCATION N° 1645
4 S.R. NO.,
�- �. r. r�
SUBDIVISION NAME SECTION , OR BLOCK 'NO:
IS''f •4 a' dt'[''=.�' ,7_ %`�` .�. LOT N0. -�^ '
HOUSE MOBILE HOME C3 BUSINESS
1 House Trailer 800 'Gal. 400..Sq Ft.
NO. BEDROOMS'_ N0. BATHROOMS � /r �'-
Two Bedroom House ''' 80.& Gal. 600 Sq : Ft.
GARBAGE DISPOSAL UNIT YES NO ❑ Three Bedroom House -';900 Gal., 900 sq Ft
AUTO. DISHWASHER YES NO ❑ Four Bedroom House 1000'Gal. 1200-Sq.'Ft.
AUTO. WASH. MACHINE YES NO ,. ❑
SITE SUITABLE .YES NO ❑
SIZE OF .TANK /o'i&U gal. ti
NITRIFICATION FIELD sq. ft:
DEPTH OF STONE IN LINES:
WATER SUPPLY% Individual. ❑ Public ❑
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE
OF COMPLETION By Qw� a
_ �-
Dam d/.r a?/ -7r
(8/16/73)
*Construction mus comply with
al'1 other applicable State and
local regulations
IAT AREA
a,, �`aLe. - •
v3
DAVIE COUNTY HEALTH PAill
AW (Septic Tank) Improvements Permit and Certificate of Completion
-(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR ; r DATE ii a' J % PERMIT
LOCATION N? 1645
S.R. NO.
SUBDIVISION NAME LOT NO. --' SECTION OR BLOCK NO.
HOUSE ❑` MOBILE HOME Ll BUSINESS
NO. BEDROOMS NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO ❑
AUTO. DISHWASHER YES 0 NO ❑
AUTO. WASH. MACHINE YES CV NO ❑
SITE SUITABLE YES CO NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual,� ❑ Public, ❑
IMPROVEMENTS PERMIT BY
I
4 T
House Trailer
800
Gal.
400
Sq.
Ft.
Two Bedroom House
800
Gal.
600
Sq.
Ft.
Three Bedroom House
900
Gal.
900
Sq.
Ft.
Four Bedroom House
1000
Gal.
1200
Sq.
Ft.
INSTALLED BY L. n 41'24r
CERTIFICATE OF COMPLETION By7
�� _ ��_ Date '?�� �
(8/16/73) *Construction mus comply with all other applicable State and local regulations
LOT AREA A7 �/ (\aJ'cL-
T-OV
4
.; DAME COUNTY HEALTH DEPARTMENT
: a
(Septic Tank) Improvements Permit and Certificate of. Completion
(Ground Absorption Sewage Disposal System.- G.S. Chapter 130 -Article 13C)',
.
OWNER OR CONTRACTOR, J 1 (� DATE .;j / 6 % PERMIT
`
LOCATION �', v. r }� �.l: C`!...- .•>, Pa# x 1� cvs .,?d, ,-cam., ��• . 16`tA
5
S, Re N0.
SUBDIVISION NAME (y N 7V4_-_ C,' L=,; WMS LOT NO.., 4SECTION; OR BLOCK NO:
HOUSE MOBILE HOME BUSINESS ❑ 1
�j a House Trailer 800 Gal -400 -Sq' Ft.
NO. BEDROOMS NO. BATHROOMS ). y .`
TI i.wo Bedroom .House 800'Gal.. 600 -Sq .Ft:
GARBAGE DISPOSAL UNIT YES NO 1❑ Three Bedroom House 90& Gal., 900 Sq.' -Ft.
AUTO. DISHWASHER YES NO ❑ Four Bedroom House 1000'Gal. 1200,Sq.'Ft.
AUTO. WASH. MACHINE YES NO ❑ ,/�
SITE SUITABLE YES NO E3:,
��� s tTyti`r
SIZE OF TANK /Sj�ffV gal.
NITRIFICATION FIELD sq. ft. y �.:5
DEPTH OF STONE IN LINES:
WATER SUPPLY:.,Individual. ❑. .Public ❑ °
IMPROVEMENTS PERMIT BY r INSTALLED BY
CERTIFICATE OF COMPLETICN Date Rl- 7r.
(8/16/73) *Construction viusM comply with all ot:her,applicable State and local regulations
LOT AREA a JQ
DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 2702E
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
(1 and/or Site Evaluations
NAME2� F
LDATE ISSUED//V07
ADDRESS (� / ,i,,E' % j' —t�' PERMIT NO.
Explanation of charge
AMOUNT DUE,` SANITARIAN
PLEASE RE1.IIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATFM NT.