379 Howardtown RdAUTHORIZATION NO: 0524 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
PeiftiideNe's P.O. Box 848
Mocksville, NC 27028 Subdivision Name:
'Name:.,
Phone #: 704-6.34-8760
Directions to property:. AL. -I _W1114 -10i Section: Lot:' -
AUTHORIZATION FOR
WASTEWATER
Tax Office PIN:# 0/
SYSTEM CONSTRUCTION
Road Name: 7* juct cLTD W I Zip: AVOAJ
**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 Forni/Authorization Number should be presentedto the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I I 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.
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
F�rrwf�ee s ;. ff
.Name: �lt,:i✓'rli c��'"/1 Subdivision Name:
Directions to property: TRY. r..� .i -r� ,� Section: Lot''
IMPROVEMENT /
1 PERMIT Tax Office PIN:#
Road Name: 711", 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
y' j ,` - t J" %~) r r� ,�.A ` ' / 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 //7 # BEDROOMS--? # BATHS , # OCCUPANTS. rte'' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE=il!%� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE AG LZ GAL. PUMP TANK GAL. TRENCH WIDTH C ROCK DEPTH /-2 LINEAR Fr. f� T)
OTHER
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.
OPERATION PERMIT
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SYS'I
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AUTHORIZATION NO. =C OPERATION PERMIT BY: DATE: Jr.
"THE ISSUANCE OF THIS OPERATION PERMIT SHAIIINDICATE 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 PER ATC
'16 Davie County Health Department
Environmental Health Section D
P.O. Box 848 SEP 1 8 1996
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed ��AV U lti/f�Sf%C3lJ/L�� Contact Person %4 V/P /y• 1 ^�/¢Sff�y
Mailing Address 04 Z A,'0WAi20 i D wN RP Home Phone f��� 9 `J�0 6-y y "�
City/State/Zip,46CX5V144E ; Al?-,- 2 ?OZ.9 Business Phone 96.9 72,5' Q Y7
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3 Application For: [ ] Site Evaluation Improvement Permit & ATC ( ] Both
7 4 System to Serve: House' [ ] Mobile Hom [ ] Business [ ] Industry Other PDV /3Z 2 ` W1 DC
( 5. If Residence: # People # Bedrooms_ # Bathrooms 2— [ ] Dishwasher [ ] Garbage Disposal
IN
X 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: [ ] County/City Q Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes NA No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***�,LAT.OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN:
Property Address: Road Name s 161.4 R12 n2 W_ZZ AE"O R161(T PAI P9411l- RD
City/Zip 4&eKS.K14Cd 9�/e ZTOZ f� ; �eF r D,l 1-t1pwa2o 7-ewnj e,61Z 44
If in Subdivision provide information, as follows: ,y r Citi 11 ull;)ePre wAl PC>
Name: 4 0SsTop ti! / au 1 Z J5' .
Section: Lot #: dy /-45,-r /,/ .l30/vv d F IZ,0,40
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 e(L YL(, ! to conduct all t
DATE q- 17- 14'-'1611 SIGNATURE
Re ised DCHD (06-96)
0,Va if [6L � le— 71(07L-
eed d - -5
na+
on c�
to determine the site suitability.