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1509 Underpass Road Lot 13ION -NO: �I 19 3 DAVIE COUNTY HEALTH DEPARTMENT 3"2s- 9Y Environmental Health Section PROPERTY INFORMATION Permittee's �„ P.O. Box 848 Name: q' -f- Mocksville, NC 27028 Subdivision Name 1° . MZ �` f Ul Phone #: 704-634-8760. Directions to property:?15' Section: Lot: �•.`fi`3 AUTHORIZATION FOR WASTEWATER„ --* Tax Office PIN:# SYSTEM CONSTRUCTION Road Name: ; Z p: dC� **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 110 DAVIE COUNTY HEALTH DEPARTMENT ti IMPROVEMENT AND OPERATION PERNUTS PROPERTY INFORMATION Pe Nae' _ Subdivision Name: Directions to Property: -SYS/ x�L � 00:"y Section: RdPROVEMENNT T Tax Office PIN:# d10e **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) nstallation 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) f � 1***NOTICE*** TEO PERMIT IS SUBJECT TO REVOCATION IF SITE �0?- a 01rPLANS 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 991�' eW BEDROOMS # BATHS _L # OCCUPANTS GARBAGE DISPOSAL: Yes or No _ COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/swr #SEATS INDUSTRIAL WASTE Yea or No LOT SIZE, L24- TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) u" NEW SITE A---- REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE /"—GAL PUMP TANK , GAL. TRENCH WIDTH y ROCK DEPTH -A2_ LINEAR Ff. S _� , OTHER REQUIRED SITE MODIFICATIONS/CONDTITONS: IMPROVEMENT PERMIT LAYOUT 1= Mv- "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)6348760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. —14. 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. DCHD 05/96 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQ11UIRED INFORMATION IS PROVIDED. 1. Name to be Billed 1?467-2— Contact Person cam► 4ii eP�TJo Mailing Address , g 5 Home Phone �� City/State/Zip4A) t- /C/ c%��i Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation Improvement Permit & ATC [ ] Both 4. System to Serve: [ ] House [ 1 Mobile Home [ ] Business [ ] Industry [Other 'n —1 5. If Residence: # People # Bedrooms # Bathrooms / [ ] Dishwasher [ ] Garbage Disposal [ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: Q� County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ J YesNo If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***,Vn ?tkfC OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: I/D Y 2oo ; WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #-S� - (,3 4 F4 6 - Property Address: Road ame,-,tkpmo Qc� City/Zip l U 21J D L If in Subdivisiorn� provide information, as follows: Name: U Section: Lot #: ' 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 falsified 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 101A?r Revised DCHD (06-96) all testing procedures,as necessary to determine the site suitability. THIS AREA MAY $E USEI) FOR 1JRAWINC7 YOUR SITE PLAN:- 11 LAN: - , E�J b), � � v P asi p) Ju r DAVIE COUNTY HEALTH DEPARTMENT 10..- (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter.130-Article 13C).` OWNER OR CONTRACTOR (', ::, ,, a �..t �r:. ,..s i s_� . DATE Jr?.�,` f PERMIT O :C0 LOCATIONS LIk,<�.,,.,.� l c-'• l 1G89 S.R. NO11 SUBDIVISION NAME LOT NO. J SECTION. OR. BLOCK NO. HOUSE CT MOBILE HOME t3 BUSINESS ❑ ` "'' House Trailer 800 Gal. 400,Sq. Ft. NO. BEDROOMS NO. BATHROOMS Two Bedroom House 800 Gal.'-- 600 Sq. Ft, GARBAGE DISPOSAL UNIT YES ❑ NO 0" Three Bedroom House 900 Gal. 900 Sq. Ft. AUTO. DISHWASHER YES ©-' NO ❑ Four Bedroom House - 1000 Gal. 1200 Sq. Ft. AUTO. WASH. MACHINE YES C3- NO ❑ SITE SUITABLE YES ❑ SIZE OF TANK gal. NO ❑ %00 %�``'�r� NITRIFICATION FIELD sq.. ft. W 3 yz V n letw"C. DEPTH (C STONE IN LINES: WATER 1.1 JPPLY: Individual ❑ C\ Public � IMPROVE:TENTS PERMIT. BY ,,0 INSTALLED BY CERTIFICATE (8/16/73) LOT AREA OF COMPLETION +� BY--� �'`" _ lam- Date / *Construction must comply with all they applicable State and local regulations fi l 1 OF COMPLETION +� BY--� �'`" _ lam- Date / *Construction must comply with all they applicable State and local regulations fi 4 J LARRY c A,� 11 y _ i ) ' • -'nrr,n�ston exaf�e/. FINAL APPROVAL L U'T 15 1. sGtT J e.1 a ti astly tat 1, �C AR q r' G I� thM rq we hser hM (in wb&W =my anile by M) (M/ eeiaipbw I'+ifc ar rocwlM M 6aM hf 9" of A•+nrnCeeeb If. G i W* tbtt Th.) (MMI)• that the erre, it deTre n alatMM1 y -w d y � � �! 7¢ maw. -.w 1ro'Mo M k .nee tlnt -- Dr+wlll c01e 19l_-. tfo bWAAWN Rd arwis/ an Oilla of Yew fess �MIYl Iwo Mlrr• Ylkem ory�hae/ Md eMarlM foN tYs « No Mwi in 3" Pep tr»� thM me on L. MMMT in aTmdi a& " 47.30 a unah . Whin m r bel MW % rel #AD tom. AD. 19 - fie' - � OMee4or of NerwsirK rwerr dAMIMW MT tate/einiee ac.Yee• Cf1ft�NM—/.err C01lMTT tK�7M GfOIgM—fNir RrJ/lT t. ltt u ' i t 0 �t L. Porra 4 A. APIs 3 ♦r �i It � 0 /3~-E f7oi.AI' 3aLae• 3e0.e• ;N.r 3i0.0• ] ..�• Il.e>.• h M M e' 2 IF h b w VAfsAr 1./is /Teles= q APIA• 4.7)fAc/!it .i � N r + w K v N b U aR• FL.OV o i I% � I � I e J � O �VTILrti ts-r ARUr g, 1a1 Aftei I • I • I tt t i �N-I>•-oza3"-w i1. �7 IbS•�• All" •sale �t tee+ J �yJ— .Aw� . t r -. . >,..r •'i - o. .. , .. .y :: rMt. . .,. .:,,� Il►E7'I Fl6 IZATION NO: 4 , DAME COUNTY HEALTH DEPARTMENT - Environmental Health Section PROPERTY INFORMATION Permittee's +� { P.O. Box 848 Name: Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 Directions to property: ��U��'�rS /- Section: / t=F AUTHORIZATION FOR y��'`o(�y✓c 1 �r;)�' WASTEWATER SYSTEM CONSTRUCTION Tax fficePIN:#'-:�,1�"",,�. A 6 — t �r Road Name:'' -fir **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. (Incompliance with Article l l 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 SPECIAI IST DATE ISSUED DAME:COUNTY HEALTH DEPARTMENY " IMPROVEMENT AND OPERATION,PERMITS PROPERTY INFORMATION. i PeAttee'"s. Name:Subdivision Name t Directiotls to property: . i .t s:. f a -Section. E14PROVENUNT + d v`�" �.3c� r✓,1 PERA¢IT J Tax ce PIN: 0, ; load' Ne: Zip: +' **NOTE**This Improvemeaf Permit DOES INOT audwrize the constiuction'ot i1lstallatibn of aseptictank- system or- any, wastewater system. An" AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCHON:must be obtained'from this,Department Prior to the ' { conslruet on/mstallation gf,a;system:Qr the issuance of.a building permit.: } , (In compliance with Article 11,of G.S. Clapter. I 30A, Wastewater Systems, Section .1900, Sewage Treatment and Disposal. Systems) t ss*NOTICE*" THIS PERMIT LS SMECP To REVOCATION IF. SITE, PLANS OR THE INTENDED U $E CHANGE. 'YOUR WASTEWATER • ` NVIRONN7PN I AL HEALTH �S1 DATEDp1 E SYSTEM CONTRACTOR MUST SEE THIS PWHT HT•BEFORE - j r INSTALLING THE SYSTEM, it RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS j' # BATHS _�� # OCCUPANTS _' GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACRITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Ye's or No LOT S1ZE TYPE.WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) v NEW SITE REPAIR SITE x SPECIFICATIONS: FICATIONS: TANK,SIZE GAL. PUMP TANK GAL. TRENCH WIDTH G (! ROCK DEPTH42 1 � LINEAR Ff.s A� OTHER ' REQUIRED; SITE MODIFICATIONS/CONDITIONS: r **CONTACT A REPRESENTATIVE OF Tf IE 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 (336)751-8760. OPERATION PERMIT cvcTr7U Tyrer t cn DV. Y/ liL 'A 'j m, DAVIE COUNTY HEALTH DEPARTMENT/ IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee's X Name: Directions to property: i Subdivision Name:' Section: _.Lot: IMPROVEMENT ` f PERMIT Tax Office PIN:#= Road Name !��.Ay'11� ZIp f' **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 constructionrnstallation 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 DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 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 WATER SUPPLY I DESIGN WASTEWATER FLOW (GPD) y NEW SITE REPAIR SITE v SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�G (/ ROCK DEPTH�LINEAR FF,/� 7 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 IMPROVEMENT PERMIT LAYOUT #APPROVED EFFLUE11T FILTER* &RISER(S) IF 6"l DELOW FINISHED GRADE- 1 _ **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 (336)751-8760. OPERATION PERMIT( ,�_� �' J� SYSTEM INSTALLED BY: V 1 1 NO S OPERATION PERMIT BY: k / DATE: AUTHORIZATION �% r i i l **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 05/96 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Y � .4^T. (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)• OWNER OR CONTRACTOR o • DATE%. %` !� PERMIT LOCATION. ��,rt,.f,L..,.r-`= -- - - -- - �� 1689 r�M S.R. NO. SUBDIVISION NAME kr}Jtj a, ..; r.�-c. LOT NO. SECTION OR BLOCK NO. HOUSE [l" MOBILE HOME ❑ BUSINESS NO. BEDROOMS NO. BATHROOMS GARBAGE DISPOSAL UNIT YES ❑ NO 0.,.. AUTO. DISHWASHER YES [ NO ❑ AUTO. WASH. MACHINE YES ©` NO ❑ SITE SUITABLE YES ❑ NO ❑ SIZE OF TANK gal. NITRIFICATION FIELD sq. ft. DEPTH OF STONE IN LINES: WATER SUPPLY: Individual ❑ Public IMPROVEMENTS PERMIT BY ©-. CERTIFICATE OF COMPLETION Byy�� (8/16/73) *Construction must comply with all LOT AREA House Trailer Two Bedroom House Three Bedroom House Four Bedroom House 800 Gal., 400, Sq. Ft. 800 Gal. -600 Sq. Ft. 900 Gal. 900 Sq. Ft. 1000 Gal. 1200 Sq. Ft. INSTALLED BY fl -j- ther applicable State and local regulations DAVIE COUNTY HEALTH DEPARTMENT P. 0. BOX 57 HOCKSVILLE, N. C. 27028 (704) 634-5985 Statement for Septic Tank Improvement Permits and/or Site Evaluations NAME�/�;, (�,,,�;, 7'. DATE ISSUED �3 s�� r ADDRESS PERMIT NO. Explanation of charge Ll�Jo_. / /� 13 en s AMOUNT DUE fs',o�b SANITARIAN PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME 1p�lg 7/A&A-7 fie— PHONE NUMBER ADDRESS Z, <U /�f/T SUBDIVISION NAME LOT # /3 DIRECTIONS TO SITE DATE SYSTEM INSTALLED � -/'? � NAME SYSTEM INSTALLED UNDER ChU47I 6�,SV a a—,• TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED TYPE WATER SUPPLY t2)' SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 A:A ,p��, �i.51