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125 Ben Anderson Rd _ _ _ _ . ,� � •f\L{�r`� fi.. ''�.�� � Permittee's_-��. ,� � � � ��i �{�AVIE COUNTY HEALTH DEPARTMENT Name: ----+' �`'1� ..��� �-'`° � �'�'"'� Environmental Health Section PROPERTY INFORMATION Q� j,-y jj P.O. Box 848'� f� f, ,,-�.:� !f 7 1 r�. Directions to property:, � ��� Mocksville,NC 27028 Subdivision Name: .�t�� F'"�) 1 L � f�l� ��`�;le:� _�r�lr�L � Phone#:336-751=8760 Section: Lot: ;� j,.'ti ._, �!•-, ." � � AUTHORI7.ATION FOK � ''���`� ;;_-��C�� �°�".����%-�C����� �r�j n�,,��, w'ASTEWATF,R Tax Office PIN:# - - SYSTF,M CONSTRUCTION AUT'HORIZATION NO: ������� A Road Name: f-�� 'r} '�� ��"�Zip� {� t .� .r., . 4 �_.r.,, .�,� **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 Fonn/Authorization Number should be presented to the Davie Counry Building[nspections Office when applying for Building Pennits. (ln compliance with Article l l�c�f-G:S-Ghapter 130A,V1%astewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ;'/ .-^..' , ; �'`'""`�'' i'� � ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION (._..P----""'� �r,',���' .� �' ,�---.;'�� �� �� /�,�n(�" IS VALID FOR A PERIOD OF FIVE YEARS. ENV1R0 MENTqL}�EAL.H SPECI`ALIST DATE ISSUED �_.,. RESIDENTIAL SPECIFICATION:BUILDING TYPE ��V-%C= #BEUROOMS �� #BATHS �- #OCCUPANTS �� GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No �" r-S �.,/ /- LOT SIZE�'(-�����TYPE WATER SUPPLY ��'"�'�' DESIGN WASTEWATER FLOW(GPD)�-'L.L'� NEW SITE REPAIR SITE `� �:'� � n '?..��", � SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `"� ROCK DEPTH � LINEAR FT. `" ` "" f, n � OTHER �``�L.�-r`T k:-�,7 .�� � � �-"1��G�71 Gw.� "��}�'j����rr�..� �� f� .0 �:, REQUIR�D SITE MODIFICATIONS/CONDITIONS: ���'=���U �� �`''`���� / !'_�AsI:-�, ��/,r��C�,'��\ f�-�"f�.i' IMPROVEMENT PERMIT LAYOUT � ���� ��_,..._______._. _... r-�',,. �{�' . .- �:t c�w���� r` t e �'--,�,,;��,i 4.'�'i ix,hla.) -"7U . -,--"'�.���_.� ..--""'..�,..---�" .�� � „� {'�I,�,p^°�`"...C`�, �.,._.---�; �.v..:-io � _ ._.y .1.:�,>!�°�1.--� ��'4'.�-�'��_�_._, w.^'" _�--�----� ��.31 `��:,;,�:-��', :...,.. 1 I~��%� � �'j ��i�.1`�:.:.1 �. ,.R� .�..__ �,, �`,f/`�'�� �2' � t � -��r11,��.�,�� -�s`_-�`�rJLt� i�'� '�'i-�` `�7��'�.vuJrJ $-�' - e,�� , , '�, : _ ��..�..�,„ �`�_:_. ,. � . ��;�}-,� ___�-_-_�� — � �r��,�r.�- , , _., �,����LL i rJ a=,,,,�,�,..��, n.lY�v.� !�� �.;vi: _ �--, -- "%:=.vrh F ��,�....a � ,�,t� rtl�.;�.�=---._. FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT�' � .� �L` - �.��� + � �� i� SYSTEM INSTALLED BY: � ����� • ! CN��."Q.S �g � � �...��S ' �� -� .�— Ta����,v-�-*'`�-S �� s �f�o',�� tl.� � �-�1.,����c� ��°i�� ; � � ;���� AUTHORIZATION NO. ��C' -` OPERATION PERMIT BY: / ATE: �� � �� *•THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTE S D ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND pISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. nc►inotioz cR���:�a� �C-��� (o� 1J✓vZ�ic' #- Jr?;� ; . �., ._ .,,.._ ,: .. , �~ •, � i', '49. y r �"'',�..-� �'�`t f+. � ' g�� � i — - - _ Pefmitte�'`5"� � ' :� � r���i�.��?AVIE COUNTY HEALTH DEPARTMENT Name: �"�+��� � -f`���t``' � �j� � Environmental Health Section PROPERTY II�iFORMATION <)� - "r`�" �.- � � � � P.O. Box 848 ¢ (� . _3,�....-:. � �� �I,, '1� ; I/"> Directions to property; � ' Mocksville,NC 27028 Subdivision Name: 19 -�'� { �+ . �� '( Phone#: 336-751=8760 .i�� � �''~� � ' !�,,i "f`,1 �,. ,F�.�4" r Section: Lot: � ,!• 1 � � AUTHORI7,ATION FOR , i..�.� �1 , �.r� ,t t.,�'`'��"�•c��� ► !'.r,(�L� WASTEWATER Tax Office PIN:# � '' -' SYSTF.M CON5TRUCTION - - � AUTHORIZATION N0: a p���� 1� Road Name: '�.� ;� �•''�J '"�'�Zipi'� ^.�� '"'~-', **NOTE**This Authorization for Wastewater System Construction MUST BE iSSUED by the Davie County Environmental Health Section prior to issuance of any Building Pennits.This Fonn/Authorization Number should be presented to the Davie County Building Inspec[ions Office when applying for Building Permits. (ln compliance withArticle 1 l,pf-Cr:S:--Ghapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems) : i .r'7 i' � � '!�""`� �s ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION ,_._ � ��� J��{ J t i�.---�' ,�''i a :+�'� - ' � `/''�'� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRO MENTAN.`HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE f���U SG #BEllROOMS L� #BATHS -- #OCCUPANTS �'/ GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE ��-�� �"TYPE WATER SUPPLY ��'L� DESIGN WASTEWATER FLOW(GPD)n�L?�--�� NEW SITE REPAIR SITE " . _ �. '. _``, 1 SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `�� ROCK DEPTH�7�\ LINEAR FT. " I? /'� -,. � � y OTHER j��'L��''� ""� ` t`�,���1��,.���7.J �'��::�Lo'"!'.'�..../ /� �-!,I �..^' f REQUIRED SITE MODIFICATIONS/CONDITIONS: �i�� ��L �PS �''��p�'��i� t �ff.j%�, �u r����� /'�' r IMPROVEMENT PERMIT LAYOUT , � � ` � __` .,.� ..._._ � __ ..., ! ,,,✓'''"r w�H �� _-�� . _ _ , y ��� -�, r' ' .�,..,..:., .-...---y_..+��^�ti 1 l—i 'f�t.NJ� 1�-'_. " �...-,•^"�' ��\ . - �_`_"� \ �. �_ �-;.. � ' "'l � � �....�.�"�'�''Yy `_ � . � .- ;. ........ -,. ' .iv� ��i . � , � ..� �..��� C�TM�,_...._ .,._. ,,,.. ._..�7 � "` �� "1,...-�/`a�,.C.' C..i� :,, .E ,p,� �,. , - T ►� , � .�....._.._._.__... � - ., _, ..:.. . �.,�..,_..-.-.-�; , �_. �.. .�' _ _ \ ,,,f-' i ►� ► . � `�.� `'�` :-y(�/�,,�� "��,,.�,�,.r.�t�._E\ i,,��;.. i"1-� � • '`t[.i��'L'��'� ` �,��> ;.y,� � . .� ,�.... E�C��:--�� ,<, —t�� — : � r-j�u rJr � ....--- '- ,-, ' , ,. t�. � `Lr•�t.G�- i� ¢. ��l..),�.1 ' � l:�.t S..,(,i+� l �.C�. Iv �..i:vr�✓1 F'i��� �E� -tl��c�-.c.. FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT,;',- ;y' ���,) �'��LL�� - SYSTEM INSTALLED BY: �� � S �N�1�1/?�;�5 �,�--�.. ..--------_' { �5� GF1�.�E'xz�S , � �:.r----- 1 -:�.� ..�5 � ►� ..� ,�..--- 'I�i n l. ��„ -1 �,ta n < �� , � n� ,( �Q�-� . r �I C� �I �-0 GI����'—' "> !-1 c�Si � ,� c _ --�'=r.z..r��..t r ��� r AUTHORIZATION NO. Z���� "� OPERATION PERMIT BY: � � � � "' � DATE: �1 3� v�''� ...----' �.._/; '*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTE ��KTSE�AB�OVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAP"fER 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. DCfID 02/02(Revised) ����,�/ 4�/(c/ �°JNd r� � 5?:�'� . . . �.��� �2���-� ��v�ad,� d�v � /�r���• � E. C_�jjo�� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTIO � ,s�,��7bi�(� V��,7 ''�' APPLICATION FOR IMPROVEMENT PERMIT(REPAI� NAME �a rI l� ���5� PHONE NUMBER J3�0 T7 G—��r� ADDRESS /v�J` c�/jl'AIIJ�P��(�r� /C�,/6��I�f�Y�//� SUBDIVISION NAME�= �G� � �-° � //� LOT # ��� ° ��/ • DIRECTIONS TO SITE ll1I�I /�', �tL' ��� �C����� V`I . � / /`YI/I�.� T(1l/(I ��f' PG� . Z���c�s � 6�l ` /s��d�� � -� DATE YSTEM INSTALLED� 1ZS NAME SYSTEM INSTALLED UNDER ? �"� ''`�"�'� � �``� vr �� TYPE FACILIN NUMBER BEDROOMS � NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �(/f�''IOS �� �G�fYl��� ` � �- � i N 1�Ase -F. Q1 G� a `� DATE REQUESTED I�`�.J-'C��J INFORMATION TAKEN BY ~ This is to certify that the information provided is eoneet to tha best of my knowledge,and that i understand I am responsible for all chazges incurred from thia epplication. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rsv.1 J93 ` '��m�� . 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