P0848 Hwy 601NAUTHdkIZATION NO: 0848' DAVIE COUNTY HEALTH DEPARTMENT ' 3�
-' Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848
Name: Mocksville NC 27028 Subdivision Name:
Phone #: 704-634-8760
,Directions to popert3� y Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PI
J SYSTEM CONSTRUCTION � -
-
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 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 FIVF, YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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LTH DEPARTMENT
DAVIE COUNTY HEA
PROPERTY INFORMATION
IMPROVEMENT AND OPERATION PERMITS -
ppb ° Ci
t',x. Subdivision Name:
Directions to property: ° Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# -
Road Name.
**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
'l 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 i #OCCUPANTS t` _ GARBAGE DISPOSAL: Yes or Nom
COMMERCIAL SPECIFICATION: FACILITY TYPE, # PEOPLE # PEOPLEISHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ""'"'^ TYPE WATER SUPPLY 43 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE "
SYSTEM SPECIFICATIONS: TANK SIZE ^' GAL. PUMP TANK - GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. / 7y
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
I
"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 L7 J P\ `Phr O
SYSTEM INSTALLED BY:
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AUTHORIZATION NOO C6 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)
COUNTY HEALTH DEPARTMENT ' C'
IMPROVEMENTAND OPERATION PERMITS PROPERTY INFORMATION
Subdivision Name.
:Directions;to'property. Section Lot
1 "' `a`+. 1 m , 4@ ''. � • ; . `,j � ; IlNPROVEII�'1VT ' ;
PERNIIT: _
Tax Office PIN:# -
ti Road Name Zip:
**NOTE-. This Improvement Permit DOES NOT •authorize ihe`constniction or installation of aseptic tank system or any; wastewater system. An
AUTHORIZATION -FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this pepartment prior to the.
conshuctionrmstallation of a system or the issuance of a building permit
(In compliance with Article 11. -of G.S: Chapter I30A, Wastewater Systems, Section 41900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT I.S. SUBJECT TO.REVOCATION IF SITE
PLANS OR THE DUENDED USE CHANGE. YOUR WASTEWATER, ;
r SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUELDING`TYPE ' b">s # BEDROOMS "I .# BATHS # OCCUPANTS _ GARBAGE DISPOSAL: Yeso
'
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS 'INDUSTRIAL WASTE: Yes or No
LOT SIZE jTYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE I
SYSTEM SPECIFICATIONS: TANK SIZE � °' GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH / S , LINEAR FT.L_
' OTHER ,
• a
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 1:007 1:30 P.M: ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 6348760.
yob rF N
AUTHORIZATION NOO OPERATION PERMIT BY. ('��C 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 TIIKE.
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I
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) c�
NAME � AVc��S S A \ TW -0 mss PHONE NUMBER
ADDRESS a) (, () 0 12 �a SUBDIVISION NAME
\}) \ `0 Sc o ,3 ' 1, AX'Q N"" \" � • (� LOT #
DIRECTIONS TO SITE to O 1 N Q "_\ 1_5 Q �.
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY �O NUMBER BEDROOMS 2 NUMBER PEOPLE SERVED y
TYPE WATER SUPPLY W � SPECIFY PROBLEM OCCURRING
DATE REQUESTED _ q 1 1 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. 1/83