2143 Cornatzer Rd•,
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
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ADDRESS � �� � ` C� �-�14"� / �--'��-� UBDIVISION NAME
DIRECTIONS TO SITE �
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LOT #
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DATE SYSTEM INSTALLED /%/o� NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY '� SPECIFY PROBLEM OCCURRING S`��-ic-- �p c�
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DATE REQUESTED ' 0�-- INFORMATION TAKEN BY ��L ����y
Thia 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 thia application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
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tAUTHOR1zA7'[o1v tvo. '� DAVIE COUNTY HEALTH DEPARTMENT �� ��`�^ ����
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�. Environmental Health Section PROPERTY INFORMATION
Namettee's ��J�.�� ,1�[L, 1 t.�^J' � P.O. Box 848
. Mocksville, NC 27028 Subdivision Name: ___�%"" / Q��---
�' 1 .� ,� , .;;: �a-��,r'�Phone # 336-751-8760
Directions to property: _� L!� ��j i.-�iJk�
� Section: Lot:
- � � �1UTHORIZATION FOR
r WASTEWATER
(. i�i �` \. ?`��'`i �.:. t' i;a��. �� ni.y1 1 N{,�� � Tax Office PIN:# - -
S�YSTF.M CONSTRUCTION
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**NOTE** This Authorization for Wastewater System Construction MUST BE ISSCJED by the Davie County Environmental Health Section prior
to issuance of any Building �ermits. This Forni/Authorization Number should be presented to the Davie County Building Inspections
Office when'applying forBuilding Permits.
(ln compli�nce w'th Articl� 11 of G.S. Chapter l OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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`� ��t ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
(' r. ! .� �:? i' IS VALID FOR A PERIOD OF FIVE YEARS.
EN IRON AL EALTH S�GFfC IST DA� E L SUED
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. . � ~ ��„: � ' � f� DAVIE COUNTY HEALTH DEPARTMENT � i � �" `• �1 � `� � � �R '�' r',
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.�. '� �+ :"�--_ ''� 1MPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
, 'Perinittee's ----�`�
s. Name: � t c �""-ri� ;';•' t� ��i t^�� Subdivision Name: t� Z—
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Directions to property: � U � S- � � ' � �� � '" ` �` Section: Lot:
, IMPROVEMENT
` . ..,� ` : �. � • :°� t.`� � >�� � � ;.,� PERMTT Ta�c Office PIN:#
' Road�Na � e. : �� �t �,�"� ► �'�- r `'��p ' ';'r �;.�
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system. An
AUTHORIZATION FOR WASTEWAT'ER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constructio�nstallation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S. Chapter �30A, Wastewater Systems, SecUon .1900 Sewage Treatment and Disposal Systems)
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; / ""1 ***NOTICE*** THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE
,', �''" j '�� I i ��` � r"" ' PLANS OR TI� INTENDED USE CHANGE. YOUR WASTEWATER
E I� V I R O N M E I V T A L H E A L T H S P E C I A L I S T D A T E I S S U E D SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
- INSTALLING THE SYSTEM.
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RESIDENTIAL SPECIFICATION: BUILDING TYPE �_ # BEDROOMS �# BATHS �_ # OCCUPANTS '� _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFTCAI'ION: FACILTfY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ���"��PE WATER SUPPLY .ti(�i'�1 �DESIGN WASTEWATER FLOW (GPD) __� NEW SITE REPAIR SITE J
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEP'TH � 2 LINEAR FI'. �
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REQUIRED SITE MODIFICATIONS/CONDITIONS: �I �� � � t" h � �• v� �
**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 (�/Cl?4�'�3�-�6b �
�.335) 751--E',%b�'
OPERATION PERMIT
SYSTEM INSTALLED BY: ,' 1�"1l!/1 I� �""� ,� t''
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AUTHORIZATION NO. ��_ OPERATION PERMIT BY: � DATE: 7 7—�
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA AT T E SCRIB ABO HAS BEEN INSTALLED IN COMPLIANCE
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 OS/96 (Revised)
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