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242 Westridge Road Lot 50�CZI �--•-- DAVIE COUNTY HEALTH DEPARTMENT r IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **MOTE** 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 I1 of G.S. Chapter 138A, Wastewater Systems, Section .1980 Sewage Treatment and Disposal Systems) NAME 'f ` / PROPERTY RDDRESS vJ�„'��re �!`• a�abi� DATE LOCATION //I/�—S" �/� <�'!' �✓/'� SUBDIVISION NAME �//J/�s�/'�'�.� LOT NUMBER �i�D SEC. /BLOCK NUMBER ry RESIDENTAL SPECIFICATION: BUILDING TYPE tfc° # BEDROOMS; # BATHS # OCCUPANTS •-I GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TAM( SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `'(ROCK DEPTH ��LIMEAR FT. /4 � r� 1/ OTHER o�( 7 REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 0% P�j � V.�z IMPROVEMENT PERMIT BY�/ **CONTACT A (EPRESENTATIVE 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. OPERATION PERMIT SYSTEM INSTALLED BY � 6L� =- Wit) di AUTHORIZATION NO. �� OPERATION PERMIT BY DATE f / **THE ISSUANCE OF TH15 OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 136A, SECTION .1908 "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 10/95 r**-MTE** This improvement permit DOES HOT authorize the construction or installation of a septic tank systea,or any wastewater system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION oust be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (Incompliance with Article 11 of 6.5. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Dispos lz,5ysteas) NAME'/ PROPERTY ADDRESS A%OEDI�o DATE f LOCATION 5UBDIVI5ION NAME r LOT NUMBER SEC./BLOCK NUMBER IV RESIDENTAL SPECIFICATION: BUILDING TYPE Ak)let' # BEDROOMS„ (4 BATHS E i OCCUPANTS -'/ GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE Ii PEOPLE/SHIFT 0 SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY / c DESIGN WASTEWATER FLOW (GPD) _ _ _ NEW SITE _ REPAIR SITE 1i` SYSTEM SPECIFICATIONS: TANG( SIZE OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ,-tii / GAL. PUMP TANK GAL. TRENCH WIDTH ..`' "ROCK DEPTH LINEAR FT. ✓'C ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MAST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 44 4c I[p Vj r , IMPROVEMENT PERMIT BY %f! **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:80-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE (i IS (704) 634-8760. OPERATION PERMIT jo(ou SYSTEM INSTALLED BY . 61d �r �r�(C->d 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. DCHD 10/95 �6 Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 1 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) ***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.*** AUTHORIZATION NUKSER NAME r / DATE./ / �� n �' d /' NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM *HNOTICE**t THIS AUTHORIZATION FOR WA WATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. d10' �gi ENVIM ENTAL HEALTH CIALIST DATE DCHD 10/95 M ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name Date N9 2084 Location Subdivision Name O Lot No. S2� Sec. or Block No. Lot Size No. Bedrooms -3 Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply House `� Mobile Home _ No. Baths �' No. in Family YES O NO YES,2 NO �YS,p NO E37 y Business Speculation Specifications for System: *This permit Void if sewage system described below is not installed within 36 months from date of issue. IS -0 / L ❑ i X3 X� N 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: System Installed by �r/�vscr�u f r ` Certificate of Completion Date..J/3 *The signing of this certificate shall indicate that the system de cribed "above has een 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 *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name Date Location — Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business — Speculation No. Bedrooms No. Baths _ No. in Family _ Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES ❑ NO ❑ Type Water Supply __— *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- 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 Certificate of Completion Date -- *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. i 4 1 i 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: 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 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. i • DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name _ Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size House `' Mobile Home_ Business -- Speculation No. Bedrooms - No. Baths _ No. in Family _ Garbage Disposal YES ;E] NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES ❑ NO -❑ Type Water Supply __— '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- 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 Certificate of Completion Date *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. 9 I I I � 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: 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 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. "IN ' DAVIE COUNTY , HEALTH DEPARTMENT (Septic Tank) Improvements: Permit and Certificate of Completion ,a (Ground Absorption Sewage; Disposal System - G.S. Chapter.130-Article 13C) OWNER OR CONTRACT08 ► a rc ,. E �: i +r+r Ccs. DATE -1;-+ ' PERMIT LOCATION' `t.� . A " `. N9 1499 �, S.R. NO. 'SUBDIVISION NAME LOT -NO. 0 SECTION OR BLOCK NO. ' • . HOUSE ': MOBILE HOME _ BUSINESS ❑ �.'House NO.; BEDROOMS. ! NO...BATHROOMS Trailer 800 Gal. 400 Sq. Ft. Two Bedroom House 800 Gal." 600 Sq. Ft. GARBAGE DISPOSAL UNIT YES ❑ -` N0 -.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•' . NO ❑ SIT& SUITABLE YES NO '❑ -SIZE OF TANK gal. NITRIFICATION FIELD ' o .•`sq.• ft. .DEPTH OF.STONE IN LINES: AA WATER SUPPLY: ; Individual ❑ Public . i IMPROVEMENTS`PERMIT 'BY . '{'"1'1{�.;y;d .q :' . INSTALLED BY 1 .CERTIFICATE MCOMPLETION - By t Date (8/16/73) *Constriuction must comply 4th.a1 o er applicable State and local regu ations LOT,AREA: ��. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) DIRECTIONS TO SITE ONE NUMBER��-.���` BDIVISION NAME,f LOT # DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY�lS a NUMBER BEDROOMS S� 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, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 DAVIE COUNTY HEALTH DEPARTMENT -� P. 0. BOX 57 MOCKSVILLE, N. C. 27028 (704) 634-5985 Statement for Septic Tank Improvement Permits and/or Site Evaluations NAME 061, (�3 , DATE ISSUED 1-1.2-77 ADDRESS=�� , �.�( �'p�' PERMIT NO. tz'� Explanation of charge������,,,, /u AMOUNT DUEAI,�-- rV PLEASE REMIT THE ABOVE A14OUNT SANITARIAN r - ON RECEIPT OF THIS STATEMENT.