1705 Deadmon RdPermittee's.. DAVIE COUNTY HEALTH DEPARTMENT Q
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Name: �� ��� ��-' �� �"�r� r��" � ri Environmental Health Section PROPERTY INFORMATIO
` P.O. Box 848
Directions to property: �"-' ��-� ��• 4' '� �°• ��i' �- Mocksville, NC 27028 Subdivision Name:
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'ti"'s�� ' �, � � "�.� " n' � Section: Lot:
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SYSTF.M CONSTRUCTION Tax Office PIN:# � �=' �" - �_ - =- %/�-•
AUTHORIZATION NO: Q'� ���� A Road Name: i?F,���°,��'� �i'� Zip: �� 1�' �'-''�
**NOTE** This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
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, VVastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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AL HEALTH SPECIALIST
***NOTICE*** TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
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DATE 1SSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE ����{'"# BEllROOMS � # BATHS �-�--� # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ��Z ��' TYPE WATER SUPPLY `� ' DESIGN WASTEWATER FLOW (GPD) ��' � NEW SITE REPAIR SITE �
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FI'.
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REQUIRED SITE MODIFICATIONS/CONDITIONS: ��l� w� br. 2=,`�� /�' c.� , z z��E+( ? Y� �C S Y-� i L� L,� �S ,i�i�S: �,(�
IMPROVEMENT PERMIT LAYOI�T
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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
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AUTHORIZATION NO. /� S V OPERATION PERMIT BY: � � Ij DATE: `'' �� v`�
•"THE 1SSUANCE OF THIS OPERATION PERMIT SHALL INDICAT HAT THE SYSTEM DESCR[BED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTTH ARTICLE 11 OF G.S. CHAP'TER 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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Permittee ^ DAVIE COUNTY HEALTH DEPARTMENT `�u�'7 (�('j
Name: "�- �, � i- �! ��1' � �� � r Environmental Health Section PROPERTY INFORMATIO��
.w"•r . C'.-` V'�h.: ,
. _ ; �. � � , � P.O. Box 848
Directib4s to property: '"'' � ` � • ' � ' !-' � - Mocksville, NC 27028 Subdivision Name:
. , - t e:� " i- � ; �, � i ;�„ ( '�Ph"one #: 336-751-8760
� . -' � , ' '". � � Section: Lot:
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-=�-" SYSTF,M CONSTRUCTION
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AUTHORIZATION NO: � Q � � �3 Q t� Road Name: ! - � " � ° F Zip: �' f '' �--''`
**NOT'E** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pemtits. This Forn�/Authonzation Number should be presented to the Davie County Building Inspections
Off�ce when applying for Building Pennits.
(ln compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
1 ***NOTICE*** THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
••F' r Ij'�t!` (� "�- '' '�' IS VALID FOR A PERIOD OF FIVE YF.ARS.
EpFVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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RESIDENTIAL SPECIFICATION: BUILDING TYPE �/'��1c'# BEUROOMS '�^� # BATHS �— # OCCUPANTS J GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �r2 n�' TYPE WATER SUPPLY `� ' DESIGN WASTEWATER FLOW (GPD) ��" n NEW SITE REPAIR SITE �
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
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REQUIRED SITE MODIFICATIONS/CONDITIONS: _� h � ` � � 4� �, 2 - � � � " ' z �=- -' 1C .f y -' '� '� ti : � : � ; � ti , ,�= .. , J' , { [.
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IMPROVEMENT PERMIT LAYOUT
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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
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AUTHORIZATION NO. ^ �F � � OPERATION PERMIT BY�"�`�� \ ,b" 1 � } ��� + DATE: `^ ~ `— ` v `
**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 IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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'• � � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION GI(,/b ��'� �� �
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) C��I
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ADDRESS,1 / � V �J�LfL
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DIRECTIONS TO SITE�D
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BDIVISION NAME
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DATE SYSTEM INSTALLED O S NAME SYSTEM INSTALLED UNDERrrs y,�l�i%%/P.�rS
TYPE FACILITY NUMBER BEDROOMS �1 NUMBER PEOPLE SERVED �
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TYPE WATER SUPPLY 0 SPECIFY PROBLEM OCCURRING �III�- Gf 2
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DATE REQUESTED� I'o23�U i0 INFORMATION TAKEN BY,
This is to qrtify that the information provided is eorcect to the best of my knowledge, and that I understand 1 em r�sponsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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