224 Westridge Road Lot 48-- `+.1„7 r-.' l+V jjM - '7' "9; ., ,C.:--�,dp j::- ,� q ..,.-r,na- - '... '•e'�.-. a -,--"^>• -.- ..- ,y. �,
/Permittee's DAVIE COUNTY.HEALTH DEPARTMENT
Name., Environmental Health Section PROPERTY INFORMATION
Directions toR
PA 'Box 848 '
P?oPertX,., Mocksville; NC 27,028 Subdivision Name:
Phone .#; 336-751=8760
r .� �.' Section Lot:
I Alr 'AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION "
AUTHORIZATION NO:.,
A e 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 BOilding•Inspections' '
Office when applying for Building Permits:
(In compliance with Article 1 I of G.S. Chapter. 130A;�WastewaterSystems, Section .1900 Sewage Treatment and Disposal Systems)'
f, L ,
{ **"NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
+ IS VALID FOR A PERIOD OF FIVE YEARS.•.
N IRONME L I PEC 1ST DAT IS E
RESIDENTIAL SPECIFICATIC'�AUILDING TYPE # BEDROOMS # BATHS � # OCCUPANTS' ' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes.dc No
o
t LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE- REPAIR STI'E _
,'/ 4
SYSTEM'SPECIFICATIONS: TANK SIZE - GAL. PUM TANK GAL TRE4_NCWIDTH � ROCK DEPTH LINEAR Fr. .
OTHER " " -'e7"' f - 70% jo9j(�i
REQUIRED SITE MODIFICATIONS/CONDITIONS:
ig;/. .
r .'IMPROVEMENT PERMIT LAYOUT
'*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. ORT- I:30 P.M: ON; THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
a• "SYSTEM INSTALLED BY:
4.
AUTHORIZATION NO. OPERATION PERMIT BY:
DATE:
--ilffi 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", SHALL
BUT IN NO WAY
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
BETAKEN AS k
AUTHORIZATION NO: 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 H 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.
a
IVIRONMENTAL AFALTN'SPECIALIST DATE IU
RESIDENTIAL SPECIFICATIbNAUILDING 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 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE to
SYSTEM SPECIFICATIONS: TANK SIyZE' GAL. PUMP TANK GAL. TRENCH WIDTH A0 ROCK DEPTH = LINEAR FT. %l
l
OTHER j }u/iv� "\�f ' ry ;�i[ %'/''; 11 1''"
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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 1
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
J
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE i I 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)
9~
s
DAVIE COUNTY HEALTfI DEPARTMENT
�>?ertruttee
Nafne.,_� r.._� ,
r'- Environmental Health Section
PROPERTY INFORMATION
,M`
�!
,-..
P.O. Box 848
-Directions to property: `"s' ! t
F Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760
1
F
- - _
Section: Lot:
'''rr
i E
AUTHORIZATION FOR
-'
WASTEWATER
Tax Office PIN:# -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 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 H 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.
a
IVIRONMENTAL AFALTN'SPECIALIST DATE IU
RESIDENTIAL SPECIFICATIbNAUILDING 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 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE to
SYSTEM SPECIFICATIONS: TANK SIyZE' GAL. PUMP TANK GAL. TRENCH WIDTH A0 ROCK DEPTH = LINEAR FT. %l
l
OTHER j }u/iv� "\�f ' ry ;�i[ %'/''; 11 1''"
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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 1
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
J
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE i I 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)
i Zn DAME COUNTY HEALTH DEPARTMENT
- -'� Ir IMPROVEMENT AND OPERATION,PERMITS PROPERTY INFORMATION
Permittee's r,
Name: - :�'� i' JJ <%`' i Subdivision Name % 1
Directions to property: - F ` Section: J Lot:
` IMPROVEMENT
PERMIT Tax OfficePIN:# C: N
Road Name::' Zip:
**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/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)
f ***NOTICE*** THUS 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 /—y # BEDROOMS? # BATHS 2T # OCCUPANTS. " GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY (�_ DESIGN WASTEWATER FLOW (GPD -) NEW SITE REPAIR SITE
/ I ,err
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 4 ROCK DEPTH - ZZ LINEAR Fret fIIJ
OTHER
1
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT $APPROVED Ci FLUEfrr FILTERt *11ISER(S) IF 611 BELQi : I'IIIIS %D 62P.DE,.
**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. P EPHONE # IS (7I3 V3=WX
_-.l , r a/ S 1335) 75f-1376tI
OPERATION PERMIT
T /7101'1/e —
SYSTEM INSTALLED BY:
k7 his .we
AUTHORIZATION NO. OPERATION PERMIT BY: �(7�-� 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)
•-_,. "7
*?��-'."'y'""7{ r}n-.:.vrvgwr!.,,,• --..-r •N-�_'.�a.v^-,--. ,K ,.,_ _ _. w
77
A DAVIE COUNTY 1HEALTH DEPARTMENT
Vy IMPROVEMENT AND OPERATION.,PERMITS' PROPERTY INFORMATION
*� :Eermiltee's:
Subdivisi
.f ' k
Na to ' w," rA .s�4 on Name f.%r}' a'r ' ty'
F Directions9toproperty: ' �trr sr ..y_ Section: f Lot:
T EVIPROVIENf T
Taz Office PINI
SZ 3. 40d
Road Name:' ' ;�: Zip:
**NOTE*Ibis Improvement Permit DOES NOT authorize the construction or'installation of aseptic tank system or any wastewater system. An'
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constr iction"tallation of a system or the issuance of a building pernut
(In compliancewith Article 11 of G.S. Chapter 130A,.Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
` ***NOTICE*** THUS PERMIT IS SUBJECT TO REVOCATION IF SITE
+ t PLANS OleTHE INTENDED USE CHANGE. YOUR WASTEWATERtr
EPiVIRONMENTAL HEALTH S ECIALIST DATE ISSUED, SYSTEM CONTRACTOR MUST SEE THIS PERMrr BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE ' H #; EDROOMS, ? # BATHS �. '�y
_ # OCCUPANTSGARBAGE DISPOSAL Yes or No.
COMMERCIAL SPECIFICATION: FACILITY TYPE PEOPLE # PEOPLE/SHIFT' #SEATS INDUSTRIAL WASTE: Yes or No,
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE '
SYSTEM SPECIFICATIONS.: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHS ROCK DEPTIIP LINEAR FT
_ .OTHER � /yye �'f''� , - �s+J Io: ; l:, � �, ��''� V ';'i}'- �} i x,� 1' : i ~fir t�• w
` 4 r
REQUIRED SITE MODIFICATIONS/CONDITIONS: P v`
1MPROVEMENTPERMITLAYOUT *APpOOMEFFLUENTF14TERv *RNER4S1. IF 6*', BRU M f>C"001 *
vJ
**CONTACT A REPRESENTATIVE OF THE.DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF -THIS SYSTEM ;
BETWEEN 8:30 - 9:3Q A.M. OR:1 00 =• 1:30 P M. ON�TI lE DAY OF INSTALLATION.4� EPHONE # iS •R 90-1
F .
OPERATION PERMIT �°!�
SYSTt INSTALLED BY. -
Z1.
h; e
' .• } �. _ :: �ie.: •�A �, `' �k� //- arta .
;'j
' .. . , .:ref ,. rl/' Yr •
AUTHORIZATION NO. J _AtPERATION' PERMIT BY; � 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 ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GTVEN•PERIOD OF TIME.
DCHD 05/96 (Revised)
�--�w�. -.y- — y ; � — 621fr.Y�p�•vyay.n.^�ymq--aPsv c.-�p-..�.•.•-.tea.
DAVIE COUNTY HEALTH .DEPARTMENT `
`,;
IMPROVEMENTS. PERMIT AND CERTIFICATE OF :COMPLETION
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment
Tre�IatmJent and Disposal Rules, (10 N AC`1OA .1934-.1968)) Permit Number
Name ��J.4r Ar 4191 ,T111-. /Pi�.� ,�%!/, inti; Datey���5�� N0 64-77
Location �. -- .�-?'' �� T� .fit1/ice
Subdivision Name ��,�i e Lot No. Sec. or Block No.
Lot ,Size House Y .Mobile Home _ Business Speculation
No. Bedrooms No. Baths _,_ No. in Family
Garbage Disposal YES,[] NO 2'
Auto Dish Washer YES NO 0 Specifications for/ System:
Auto Wash Machine YES, 4 NO
. W�
Type Water Supplyy�;
*This permit Void if sewage system described'below is not installed within 36 months from date of issue.
- Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- r
9:30 A.M.. or 1:00-1:30 P.M. ,on, day .of completion: Telephone Number: 704-634-5985. '
Final Installation Diagram: System Installed by �.z� 01.
.��
Certificate of Completion Date ` Q
'The signing of this, certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in .the. above regulation, but -shall in NO way be taken as a guarantee that the system will function
satisfactorily for.any given period of time.,
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*MOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name�r��., .��1�yf�s' .%t;%%�'�- �,,�' t ��Date s r'."!�/;' ND �. P
Location
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
M
Improvements permit by
*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 day of completion. Telephone Number: 704=634-5985.
Final Installation Diagram: z /''' System Installed by
Certificate of Completion Date
The signing of this certificate shall indicate that the system described above has been installed in compliance with a
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function .
satisfactorily for any given period of time.
Subdivision Name
Lot No. Sec. or Block No.
Lot Size
House '`f
Mobile Home _ Business Speculation
No. Bedrooms ` No.
Baths_
No. in Family _
Garbage Disposal
YES
p NO
Specifications for System:
Auto Dish Washer
YES
NO p
s'✓.�.e� /, j.
T
Auto Wash Machine
YES
NO p
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
M
Improvements permit by
*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 day of completion. Telephone Number: 704=634-5985.
Final Installation Diagram: z /''' System Installed by
Certificate of Completion Date
The signing of this certificate shall indicate that the system described above has been installed in compliance with a
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function .
satisfactorily for any given period of time.
ti
-p r r • +, .M1 ,.. ,Q...y.•nrr--; on'v^� '•t.i?' ".✓`'`p•p[1`i `'""WV`O'`" r - v-'tr *!•7 "r •�• , -fr - vwar^v.-r- ��v--- r- -
• `� UTHORI� Y No { `� a`�A DAVIE COUN'T'Y HEALTH DEPARTMENT
Q
Environmental Health Section PROPERTY INFORMATION
r Permittee's P.O. Box 848.
Name:
• ♦'-6*7-iQ- `%=� • *���Td A r,-�.; Mocksville; NC 27028 •. Subdivision Name: ��!I"� :�..# �•
Phone # 336-751-$760
Directions-.o"property:e�C 4�i�� Section:
� sAUTHORIZATION FOR
WASTEWATER
�. Tax Office PIN:#' qq (N L ' _; p fl, Aoa�
SYSTEM CONSTRUCTION
Road Name: " a Zip:
**NOTE** This Authorization for Wastewater System Construction MUST. BE ISSUED by the Davie County. Environmental Health Section prior
to issuance of any Building-Perniits. This FotrivAuthorization Number should be presented to the Davie County-Buidding Inspection's
Office when applying for Building Permits.
(In compliance. with. Article -11 of G.S. Chapter. 1.30A. Wastewater Systems„Section .1900 Sewage Treatmentarid Disposal Systems).
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION. ' .
IS'VALID FOR A PERIODOF FIVE YEARS .
ENVIRONMENTAL HEALTH SPECIALIST, DATE ISSUED
n� 25
DAVIE COUNTY HEALTH DEPARTMENT V ,�
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(704) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME C. C1 DATE ISSUED 7-/.)-77
ADDRESS �,. ,�(° PERMIT NO. l <
AX- -_Q1644
Explanation of charge
AMOUNT DU 6-A SANITARIAN Q,,p�02�,,J,
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT
NAME ��¢lx I
�y�7CJL
PHONE NUMBER
7 7'.Y
ADDRESS
SUBDIVISION
NAME'
% 5"72
l G
l
SUBDIVISION
LOT #
DIRECTIONS TO SITE
.
DATE SEPTIC SYSTEM
INSTALLED
NAME SEPTIC SYSTEM
ORIGINALLY INSTALLS
UNDER
SPECIFY PROBLEMS THAT ARE OCCURRING
du�
DATE REQUESTED�9INFORMATION TAKEN BY ;;�Jwx
MOM
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME ���`� A boSo "� PHONE NUMBER
ADDRESS 2 a`r` tes SUBDIVISION NAME
Ak J c�- ^ c i LOT #
DIRECTIONS TO SITE O Fir- L -lac4r-s r P24 • S )4� IL"t A �"�ow
I ss' b'i I I E,rc l y~ s
DATE SYSTEM INSTALLED 7° s ��� NAME SYSTEM INSTALLED UNDERc-:c---
2Ui Raj
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
`-f ` 3 `in ° `'' SZ ``._ �- - C p �°`'' "-
DATE REQUESTED ` 3 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that 1 understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93, J