282 Deer Trail`AUTtiGkfz logy No: 7 ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental.Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848
Name: Nc�QMi L1. 1 �1CUt�nnn Mocksville, NC 27028. Subdivision Name.•
Ac
Phone # 336-751-8760
Directions to property;, CO0 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
ZiL T 4 lt�: L� Fr FSC K Road Name:�L:(�(�ZIE �-!`JZip : 7 ->'Z�
**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 ith`Article i 1 f 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.
ENVI IALNEAL SPS ALIST' D TEMUED
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= r1' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name: ' f V (_: rVth�,l i L. l I .�) f ,1)An r; Subdivision Name:
Directions to property:;'C % hl `! c.'' Section: Lot:
c IMPROVEMENT
PERM Tax Office PIN:# -
Road Name: �' /. (: j IC_ L —) Zip:
c
**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 compliance7ith Article .l;1,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
ENVIRO M N AL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
z INSTALLING THE SYSTEM:
RESIDENTIAL SPECIFICATION: BUILDING TYPE M N # 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. W L -LL— DESIGN WASTEWATER FLOW (GPD) _ . NEW SITE REPAIR SITE ✓
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 2�.� LINEAR FT. L
OTHER (TIS l)
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 (704) 634-8760.
xxxxxxxxx
OPERATION PERMITS YSTEM INSTALLED BY: .r,% ,J
�S �-�divj
C,}4C:.c-V_ Coa- (.J4Tc(k 1011_%;-:--r
AUTHORIZATION NO. 1714 OPERATION PERMIT BY: DATE: J IX7
"*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATETHAT STEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 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 05/96 (Revised)
� — " y � r � � C f L�' ;�Y /Y•�` /! 1. �,.�:�' « . � � �� e�..+ � t ` . �'� � •.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name:` ' r•": ' L l l : )' ,t 1l� r= Subdivision Name:
Directions to property: Section: Lot:
' IMPROVEMENT
L r. ! 5 rt PERMIT Tax Office PIN:#
/ _ : 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)
***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 M H # BEDROOMS . -�— # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or Nc
IAT SIZE TYPE WATER SUPPLY L�. DESIGN WASTEWATER FLOW (GPD)NEW SITE REPAIXSTIE�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 2-4"' LINEAR Fr.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*AAPn0VED EFFLUENT FILTER* *RISER(S) IF 6" DELOW^FItHSHED GRADE*,.
10
2cy
.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 (704) 634-8760.
xxxxxxxxx
OPERATION PERMIT
' A � r°') Y k)lj ITA
SYSTEM INSTALLED BY: `"
-1 01J (\
CA v- F o! f-0 A -r c t, S 1 rT e;1 L L T
AUTHORIZATION NO. 171 H A OPERATION PERMIT BY: DATE: L
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE STEM 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] ,}
/jj// j, DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APP CATION FOR IMPROVEMENT PERMIT (REPAIR)
ADDRESS 1/
G
16! /;�/61_
DIRECTIONS TO SITE
PHONE NUMBER
BDIVISION NAME
LOT #
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED %J OU 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