152 Bailey Rd i-Permittee's , " / DAVIE COUNTY HEALTH DEPARTMENT
` �iai�e:� �`���� / .E'.- Environmental Health Section PROPERTY INFORMATION
, � � J P.O. B o x 8 4 8
Directions to property: ,��.�" �`:! �; r�'� � Mocksville,NC 27028 Subdivision Name: '
�� %� f t/'' `'� Phone#: 336-751-8760
1:^�'.�"���'Ar�'r^ °`�• Section: Lor. ,
AUTHORIZATION FOR
R'ASTEWATER Tax Office PIN:#
SYSTF.M CONSTRUCTION � � - -
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AiJTHORIZATION NO: � �-,',�; � A R ad Name: C Zip.�'Z�� �"
**NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmenta]Health Section pnor
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.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
r,.' ';f ' f.� ,:�, �,r ,, ***NOTICE***THIS AUTHORI7ATION FOR WASTEWATER CONSTRUCTION
� 1 �'� ,' :�, r :-. � �;x ���'�S� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL`NEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEDROOMS '..J #BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WAST'E:Yes or No
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LOT SIZE TYPE WATER SUPPLY L / DESIC7J�1 WASTEWATER FLOW(GPD) `�f� � NEW SITE REPAIR SITE �-""��
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� r1 L...�°'f.�'��^l,✓r ��.,,r� .y-' �� � ��.�+'1 � � ..�.i
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP�TANK GAL TRENCH'WfDTH�'"'' ROCK DEPTHf���,�t-'"INEAR �
_...�` /'
OTHER ' T t' r "5�� !/.
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: L�
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AUTHORIZATION NO. OPERATION PERMIT BY: ��I_ ��� �.,..�� � DATE: �
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WI'fH ARTICLE I 1 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. '
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�-����eri�iittees,,-`�� 1 DAVIE COUNTY HEALTH DEPARTMENT
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„;�ar�►e: i�%/'"f' :�`' �',�./�1' ' .�. Environmental Health Section PROPERTY INFORMATION
_ � P.O. Box 848 , - � �
' Directions to ro e ��='tif' ; '
;
P P Y� Mocksville, NC 27028 Subdivision Name:
, �j;',f'� �' �ti-- ' Phone#: 336-751-8760 t
� _' x Section: Lot:
� AUTHORIZ,ATION FOR �
_ .. WASTEWATER Tax Office PIN:#
" SYSTF,M CONSTRUCTION �, �
�� ��
AUTHORIZATION NO: �,F���,�.�? A R�d Name: � � IC ��'� Zip��O� �
**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 Focm/Authorization Number should be presented to the Davie County Building Inspections
: Office when applying for Building Permits.
(ln compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
,�
***NOTICE***THIS AUTHORI7ATION FOR WASTEWATER CONSTRUCTION
• : IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTALNEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATIONc BUILDING TYPE� #BEllROOMS '`-�-�« #BATHS ry*-, #OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEJSHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
fr.';''y' ,;
LOT SIZE TYPE WATER SUPPLY �":��r'�� / DESI�N WASTEWATER FLOW(GPD) —`' � �` NEW SITE REPAIR SITE ��.
:�'� .r'`� �''P `'�J�— Grt'.` � 1» _ `�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP;TANK GAL:'"TRENCH�VIDTH' ROCK DEPTH�! INEAR EI;, %'"�`�
� � t J ,. , /7
OTHER ,r.1%'f!" .,' l' ��'` r' `� �.n � "'���� !,� / [✓�E��
� , -- , �.s -
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT
�
,,,,..,/�
�"��� ,
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.OR 1:00- 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT ` /
�,n
SYSTEM INSTALLED BY: �kf - �� �'
� ��/d/,� � °���(�
, � �
AUTHORIZATION N0. OPERATION PERMIT BY: 6��I ����• DATE: � /� v-ti`'
. ,
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLTANCE
WITH ARTICLE I 1 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 02/02(Revised) . . •
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APP I ATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ` P PHONE NUMBER i���" 2' ���
7i�- y f�`
ADDRESS � � SUBDIVISION NAME
� G'� � LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLEQ NAME SYSTEM INSTALLED UNDER �
TYPE FACILITY NUMBER BEDROOMS ` NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �/(�J�iG/ SPECIFY PROBLEM OCCURRING
/
DATE REQUESTED a� INFORMATION TAKEN BY ` i
This is to prtify that tha information provided is corced to ths best of my kn, I ge,and that I understand I am responaible for all charges incurced from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT /✓L� � G�'
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