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541 Ben Anderson Rd
Y ... ., . . _ . . �• r . : s _ �` '�.U�+.f j `�.�,t.% • rPermittee's � DAVIE COUNTY HEALTH DEPARTMENT �.�,_ ` �- � _ ���.._. N�me: 1'•'�1;�l l' �• �--� ��� ��=.t�� !._� Environmental Health Section � PROPER INFORM I l' r , P.O. Box 848 'G C%;e�n✓����`of/ " Directions to property: �-�l'��'•� ��' �-1f"�� °"����,j Mocksville,NC 27028 Subdivision Nam : � �� • �� !' , ``�' Phone#:336-751-8760 iv�-:� !�-.: c'•T� �`•�:X�1:: �,r.•�4i�.i� .1,r3 Section: Lot: " , � �,� AUTHORIZATION FOR ' �";.'�;, ,J� � ,yC1 ,� WASTEWATER Tax Office PIN:# - � - SYSTF,M CONSTRUCTION �, � `'� � p Road Name: '`'�` j'�':�� �`�'�'Z� a�� . ��.�� AUTHORIZATION NO: +:.<a�s:�- I J � � ^ P��� **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior ro 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` rticle1r11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) :. r 1 'f!( �':�"`� l �' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �` � {� y � „�...{, _� �.:�,.,. '"��"`;" � �i Ir' - IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRbNI�tEN�TAL NEALTH SPEGIALIST Dr�TE 1SSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS �__} #BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE ?•lO�r'��'�jypg WATER SUPPLY �.-�- DESIGN WASTEWATER FLOW(GPD)� nf� NEW SITE REPAIR SITE � SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ''��, ROCK DEPTH I z,/ LINEAR Ff.�/ r'1 � OTHER �'"� �1��:—I ��'(1D� ��i.:� t-� �j ._() I REQUIRED SITE MODIFICATIONS/CONDITIONS: ��S)��-��- fltJ �.t�1`T'f.�l.�r � ,�6°'�� �^� �`'"t' �°'"� �—�''�''�� �V'�^`'Y '� Gr���G�t:.l� IMPROVEMENT PERMIT LAYOUT ' . " -��,%�.%�7 ��,.a�:S t,.a ��� -r ��sp�-+ �� � � C Q � C. 1 � �� � �� � ,�1 - r ►' t, t 1 � � ,�., � � �- � � G- ��J ,�� C� 'C: / t� A � � � **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 � SXSTEM INSTALLED BY: ���5 �U� . , � U!"�' ti'�� S`}`V`'� Il� �iYli�-� �io���' � � (.�`� �'�*� � � � r i r � Y, �• � � � � j��"�� AUTHORIZATION NOt���OPERATION PERMIT BY: r"��I DATE: LLf **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM ED BOVE HAS BEEN INSTALLED IN COMPLI NC 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. . 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" - ����& '_ _ � �� � �'�. �'A �� k�'e �� , �' ° � ' � �i �� �� '� , I � e.�i� a' � "h �+x� �'�� � � � � .,� � � I �� r . �"�"°a ' o���� , ��"�`� ,a� 4',�a.�� "��:�; x .'u �� �f..� . � _ . .: ' " � ' �.� .. � . . �. ,. .. . . . �� .r. ,:xf . .. _ .+,�.,'�'.� �.a . �``- � ��� . _ ; > I , � �� ���� t1G _ : � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION � � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME ��`�'�' ��-�P/� �+s'�5���`- � PHONE NUMBER �7 �2 — �d � � ADDRESS 5 Y I �-� �- �-��r�,� � SUBDIVISION NAME LOT # DIRECTIONS TO SITE �D � / � � c� r� 1--�� C �- �al �6 oJ ��""— � `f� ClC � - �G�-� 2.-� �.� s � s ���Q S � 4 � �e c.��...� v�..�.we.�-d.� ,�--`�o,..�--�-- �� � DATE SYSTEM INSTALLED � NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS 3 � NUMBER PEOPLE SERVED � TYPE WATER SUPPLY �� � � SPECIFY PROBLEM OCCURRING ��-�-✓��;�— ��'`'t`�?� �-. � � _�--- DATE REQUESTED Y( -`' y� INFORMATION TAKEN BY � This is to qrtify that the information provided is correct to fhe best of my knowledge,and that I undersWnd I am responsible for all charges incutted from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT � �.,roa � �