249 Gilbert Road - Office�i0a
AUTHOR7,7tkTION NO: U 6 4 % DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Penbittee's�r� ' ,' P.O. Box 848
Name: t''/.'Jl;.i �� �' �r •J/,s' Mocksville, l� 27128 Subdivision Name:
,� ; Phone #: 704-63 S
Directions to property: - -} :� - f ' �/ .�i Section: Lot:
AUTHORIZATION FOS "WASTEWATER
, ;
•' f✓ SYSTEM CONSTRUCTION Tax Office PIN:# - -
Road Name. Zip '1�
IV
**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)
i%/ •,� ��� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,tJ;G- j , i ; y/r t? �7 • �; '� j� /�`! IS VALID FOR A PERIOD OF FIVE YEARS.
EN�V`ILR<ONMENTAL HEALTH SPECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
- IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Peri tee's
Subdivision Name:
Directions to property: Section: Lot:
IMPROVEMENT=-
�,. PERMIT Tax Office PIN:#
Road Name �1�,1` -+ r :.. Zip: A
**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*** 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; - # BEDROOMS -# BATHS _ #OCCUPANTS qJ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY X4-11 DESIGN WASTEWATER FLOW (GPD)J 2 S NEW SITE REPAIR SITE
/s
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHS " ROCK DEPTH�� LINEAR
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
� 1
1 �
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
SYSTEM INSTALLED BY: YbNNI� L_AY-�
s
`J
�6J
964C too
— uNe.s /Vv - n1-siL�
-a
% 2 J^3 � r'`
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 05/96 (Revised)
4 DAVIE COUNTY HEALTH DEPARTMENT
t, IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Perrliittee?s . _..
Name: Subdivision Name: a
Directions to property:
Section: Lot:
IMPROVEMENT ""`'
PERMIT Tax Office PIN:#
Road Name,�"' 11244 %' Lip:
:�
**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)
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE C# BEDROOMS —# BATHS —Q— # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: ACILITY TYPE # PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY =%i DESIGN WASTEWATER FLOW (GPD),-�) NEW SITE REPAIR SITE I_-�✓
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Z, »' LINEAR Fr,- ''T
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
� 1
i
'i 04
**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 -' 1if
�
SYSTEM INSTALLED BY: )1�N1
A t C,,
&T.
(� 2 J,� z A
�1
AUTHORIZATION NO. l/ r OPERATION PERMIT BY:���`n4o 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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME Z'e 7" sy�t /J/i° i //c2��r ` PHONE NUMBER
ADDRESS 71' -SUBDIVISION�a.�,..� ,r NAME
LOT #
DIRECTIONS TO SITE_Gt�fi`
le
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY��'�- 'e ��N MU BER BEDROOMS✓/7 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY_,44: �f% 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 /' fGV-v-U �t/Gs✓
Rev. 1/93
**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)
r�
I. ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIROON'MEN L -HEALTH SPECIALIST DALE
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
1-4)
COMMERCIAL SPECIFICATION: FACILITY TYPE 'PEOPLE ! r { # 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 WIDTH S( ROCK DEPTH O LINEAR FT..
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT Ck j
M INSTALLED BY:
AUTHORIZATION NO. _:P � v 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 07102 (Revised)
Permittee's�
'
y ,,j DAVIE COUNTY HEALTH DEPARTMENT
Name: . ,)
r ,
Environmental Health Section
PROPERTY INFORMATION
_
Directions to property:��
r ! +
�� -�J
;. P.O. Box 848
,' f� Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
'
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
Tax Office PIN:# i�IrW-
24
Road Na�� "' ' i.
AUTHORIZATION NO.
A
**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)
r�
I. ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIROON'MEN L -HEALTH SPECIALIST DALE
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
1-4)
COMMERCIAL SPECIFICATION: FACILITY TYPE 'PEOPLE ! r { # 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 WIDTH S( ROCK DEPTH O LINEAR FT..
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT Ck j
M INSTALLED BY:
AUTHORIZATION NO. _:P � v 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 07102 (Revised)
4, gffaitfee's _ - �. ISAVIE COUNTY HEALTH DEPARTMENT
.�
Environmental Health Section PROPERTY INFORMATION
` P.O. Box 848
"" = "Directions to property: Mocksville, NC 27028 Subdivision Name:
t„ Phone #: 336-751-8760
`AUTHORIZATION NO:
= '✓� �"
AUTHORIZATION FOR Section: Lot:
WASTEWATER Tax Office PIN•#
'4 A
SYSTEM CONSTRUCTION
Road Nar6?/ ' � � 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 witfi Article Il of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems)
s 1 ***NOTICE***'THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
` J IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENT,AL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE
# BEDROOMS # BATHS
# OCCUPANTS
GARBAGE DISPOSAL: Yes or No
` �#
COMMERCIAL SPECIFICATION: FACILITY TYPE a�"
PEOPLE oF # PEOPLE/SHIFT
# SEATS
INDUSTRIAL WASTE: Yes or No
LQT SIZE TYPE WATER SUPPLY
DESIGN WASTEWATER FLOW (GPD)
NEW SITE
REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL.^
PUMP TANK GAL. TRENCH WIDTH St ROCK DEPTH LINEAR Fr �I
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS
IMPROVEMENT PERMIT LAYOUT
} i
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
3' BETWEEN 8:30 - 9:30 A.M. OR I:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT Y$TEM IN�ALLED BY: zxl F
64
�S
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 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 m m (ReAS4