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972 Cedar Creek Rd �.....--.+�..�w.-5,..�.;Y....--....---.,w...-r,...-,.-•.�.r . - •.r«'�-,.r.ti-+n-:..r..-....-.n-..--.r-�'�.���...r.++ix..,.+.l.nJ4+.J�-�rEw...�.+..J�+ww - - .: a ' .. . . . �� 7—�3 : ��s � �«mitt�e s � DAVI:E COUNTY HEALTH DEPARTMENT , ,..I�jaqne:,�� . ���`"�l�C�"��. �Environme.nfal Health�Section � PROPERTY INFORMATION _""/AJ ��,l.E ��-*�j�.' P:O:B�ox 848:� � . • . Dii�ions to•piop rt: . �/.' r, c �Mock'svi'1•le,NC 27028� 3u6division Name: � 3 / - ,� � / � . Phone#:336-75.1.-8760 . . .. ��i� [��;f��[:�.:�s E/� i'Y. {"" :��ill�{.` � . ' ' Seetion: . � ' Lot: � � } • . • • � . AUTHOWZATIOly1�7FOR . .�f.���� ���� . • WAS-'1'EWATER Tax Of.fce PIIV•:#. - - . . . , SYSTEM CONSTRL]CT,ION� . � �� , . ' ���� � • . . . AUTHORIZATION-1�0:. . � � -A `� ' � • • . �Road Name: . ' � Z�ip: **NOTE**Tliis Authorizatiori�for Wastewafer System Construction M:UST BE.I:SSUED by the Davie Counry'.Environmentat.Health Section prior to issuance�of any Building P.ermits.71�is F..orm/Authorization Nqmber should be�presented to the Davie Counry Building�Inspect'ions �Office when applying�or Buililing Permits: ' ' • � , ' � � (I�n�compliance��th Arti�e 1'1 of G�S.�ptet.130A;,YVastewater Systems;•.Section.1900•Sewage Treat�ment and Dispos�Systems)' ' '� . ,�, . . �% • � , ' ��' "!!NO'FICE***THI$AUTHnRIZA'.TION FOIt,WASTEWATER CONSTRUCTION • 1 . • �'�`��� �, � . . .."�'�'r .. � � IS VAL•m F�OR A PERIOD OF'FIVE•Y.�EARS, ' . � • ENVIRONMEW'A'AL'HEALTW�SPEC ALFS'1' :� DA'PE ISSUED : : • , , . •• . RESIDENI7AL SPECIEICAITON:BUII,DING 7'YPE-�_� �.BEDROOMS #•BATHS #OCCUPAIVTS ;J GARBAGE DISPOSAL:Yes or No . , • . � � • —�. . COI�RCIAL SPECIFICATION:�F.ACII.;17`Y T1'PE � N PFAPL.E,. #PFAPLFJSHIFI' N SEATS' .INDUSTRIAL WASTE:Yes or No LOT STLB � 7'YPE WA`fEit•SL7PPLY�IDESIGN•WASTEWATER F.LrOW(GPD��� NEW Sl'I"E ' �REPAIR STTE +� . , � . . . SY$TEM.SP.F.CIFZCA'1TONS: TANK SIZE GAL. PIJMP TATiK GAL•. 'I'RENCH WIDTH���ROCIC DEPTkt�,L'INEAR F!'.'� . . � . � , O'i'HER�iI/•� ./� A�'l�..: '[/•'/E /6/P -- :� `NG-� ' . . � ' , � .:.,. r . �• • -S' . . . , , i, , �It6QUIIiSD'S1TE MODIFICATIONS/,CONDITIONS:, • ' ' • � • � ' ARPROVF,MENr PERM11'LA1!OUT. � . • . � O•'J . � . . c� �- �. . � . . � � � � � � � . �a�(��a�, . : . . . . .. . . . � • ' . . . �� � � � � . . � . . � � . ' . . . . .. . . � � . . - � . . . . � . . . . . . , . , � � � . . . � � � . , „ . . . - � . ._ . r• . , . � .• , . � � � . . . . ' . . . . , � , ' . , � . . ' � • � . . • ' � �A ' . � . � � ' ' � •'CONTACf�REPRESENTATIV'.E OF TFIE DAVIE COLJ�N`fY IiBAI:TH.DEPARTM�ENT FOR�FINAL;IN�SPECITON OA'FHIS SI'STEM.� $El'WSEN•8:30-�9;30 A.M.Oit 1:UU-'1.E30 E.M.•ON.TFIE DAY OF•I�IVSTA:LLATION:.7ELEPHOIV•E.#.IS (33Gj.751-8760. � 'OPERATION PffiLM1T ' ' . ' , '� � ::. . .C. Y . . ' , . :SYSTEM INSTA�I.LED BY:.��i�D'/� • . .� �. �• � . �, • . � �. � ' ���7r� . � � � � . ' � .... . . � " . . : � • . � . . . . . • . � . , � � � . ' � � � • . � �. � . � ' • . . � . � , • � � '. . �. . . �� a,d � �� ry �;: : � � �� . . . . , � � . . � do� . . . . � : . . . • ' . • r ' . . ^ . • , � • . ' . . • . .AUTHOR�IZATION NO. � �: .ER�ATION PERMIT BY:• . � ' DA1E: ', ' '�'PI�LSSUANCE OF�TFIIS OPERATION PEWrII'f SHAI:L II�iDICA'1'E THAT TI�$XSTEM DfiSC1tIBED�ABOVE HAS'BEEN INSTALLED II►i'CQMPLIANCE ' 'W1TH Alt1TCi'Ts 11�OF G.S:CHi+P'IER�130A►,SF.CITON.190p;"SEWAGElTRBATA�N1'AIVD DISPOSAL SYSTEMS';BUT SHALL�IN NO WAY BE TAKEN AS A • GUAR�ANT�THAT 1HI3 SYS1'Sbt W1I.L�FUNC1'!ON'SATlSFACTOR�IL•1C�FOR ANY GI•VEN PBR�IOD•OF TA4E. � ��� . � . � � • ' . . i . : . . - •. . � . . � � � �3 . � . .. . . . ,;.:-. � . . . . . . . ..r.. . • : .' �� • . � . :, . . � �L � ' S � . . . �,- . . . _ .. . .. , � . ��� . . . k . �: . . . . ,� _ � �.. �. �� . . . . , ,.; . . ... .., . . . _ . _,-_ ... _. . .... - ,_. , ; { � _ �,�, .�_ � � �,s �` Per'init�ee s,�� : DAVIE COUNTY HEALTH DEPARTMENT � -� ' ,�_l�auie:� �'' ��`-"� °"`^- =-'{ j'` �' Environmental Health Section PROPERTY INFORMATION , ..._. - �- . F„1,:. a, ; P.O. Box 84� Directians to property: _�j �-r �` �� r.'� � t` Mocksville, NC 27028 Subdivision Name: "� � Phone #: 336-751-8760 � _ ' � �� Section: * Lor. '. �. AUTHORIZATION FOR ___r,' j f':�,r , , fir,� .� WASTEWATER ; Tax Office P1N:# - SYSTEM CONSTRUCTION .' - - - �� a�:+ �3� �''� .�'' AUTHORIZATION NO: A � ' Road Name: Zip: _ **NOT'E** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. 7'his Form/Authorization Number should be presented ro the Davie Counry Building tnspections Office when applying for Building Permits. (ln compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposai Systems) . � . � � ; � .r' . . ' EIVVIRONMENTAL HEALTH�SPECIALIST DATE ISSUED ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. RESIDENTIAL SPECIFICATION: BUILDING TYPE �""�_ # BEllROOMS i-� # BATHS %�"' # OCCUPANTS -�„/ GARBAGE DISPOSAL: Yes or No ti COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No .,') - LOT SIZE TYPE WATER SUPPLY t�( %'7% � DESIGN WASTEWATER FLOW (GPD) `�' �-' t� NEW SITE REPAIR SITE � SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH-.``�<" � ROCK DEPTH �°,! LINEAR FT: ��,rjL� � �� �� OTHER !j r:� I / ,Fy�G�A (/� f j ,�.- ..._. ,� : �� ._ y� . REQUIRED SITE MODIFICATIONS/CONDITIONS: _ I IMPROVEMENT PERMIT LAYOUT 0 ,- **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 - 130 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. I OPERATION PERMIT l�,,,.,, — SYSTEM INSTALLED BY: t�„TT��' /'S� � �/. , V �J /. �, !" :% ,s �y fS� RIZA N N �� S/ OPERATION PERMIT BY: ��� � D ��) /` - AUTHO TIO O. [,�[ � ATE: Q�_ **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 1N NO WAY BE TAI{EN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ncH� ozroz ����s�a� fi� �',�_ ���!_ !, ' � � �� � � � --�`- .� ��� s DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) PHONE NUMBER � � g ���� � ADDRESS � � � Ce ��^ �'�� �c-C � 2--� SUBDIVISION NAME � o �-�s� �I�� LOT # DIRECTIONS TO SITE ��-g � ��2�'� a(�c� �,..� ��'v I - � � e ('-�- S � /1 cC • � l-�,� '('- , �� °Y DATE SYSTEM INSTALLED _i1e-�-� � p�� f e. C� Z 4 S �' � ME SYSTEM INSTALLED UNDER " �n���� �-L��- TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED � TYPE WATER SUPPLY � P II SPECIFY PROBLEM OCCURRING � � n� ��� P� DATE REQUESTED �(� o S INFORMATION TAKEN BY � This is to qrtify that the information provided is oorrect to the best of my knowiedge, and that I understand I am r�sponaible for all charpes incuned from thie application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Hev. 1/93