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At�7HORIZATION N0: ' DAVIE COUNTY HEALTH DEPARTMENT
t - Environmental Health Section PROPERTY INFORMATION
Permittee's /, ! P.O.Box 848
Name: 1 �r/ Mocksville,NC 27028 Subdivisi6n Name:
Phone# 336-751-8760
Directions to property;��l��lfrz�w ,� Section: Lot:
f ,I� AUTHORIZATION FOR
r!!�h/S G� ./✓. !T_ WASTEWATER
Tax - -
t' TOffice,PIN:#
SYSTEM CONSTRUCTION ,
y�7 'Road Name:
Zip:
**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 Form/Authorization Number should be presented to the Davie County Building Inspections
Officewhen applying for Building Permits.
(In compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ',"
j
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALM FOR A PERIOD OF.FIVE YEARS..
.ENVIRONMENTAL HEALI H 4SPE:'
DATE ISSUED
,TR ,,.�.—� .•�- .. -�, _..- -,.r.—v„' r--T" -a�y`a ..,.*,�. ,�,:.i'^'a' ,y%Y'S%rs,.-i`W'75,sr..h':.*dS''V:.-•, kt, ,,.^ �'Rrk.Tu.,.r$'t";
DAVIE'COiJjNTY HEALTH DEPARTMENT r.V
IMPROVEMENTAND OPERAT ON,-PERMITS PROPERTY.INFORMATION.
-Pert itte �s
!.Name: .. . f'. '. Subdivision Name:.
Directions to:property: !� `.zwirk +' f ' Section: Lot:
POPR NT
�/�. T .� P 1 ff
.Tax Office PIN:#. -
— ,
d, Road Name:. Zip:
**NOTE**This Improyement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must'be obtained from this Department prior to the '
wconstnictionlmstapation of a system or the issuance of a building permit.
(In comphance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section:1900 Sewage Treatment and IDisposal Systems)
s' ***NOTICE*•**THIS PERMIT IS SUBJECT TO REVOCATION IF SITE,
:PLANS OR.THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL-HEALTH SPECIALIST' DATE-ISSUED - SYSTEM•CONTRAC T'OR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.'
RESIDENTIAL SPECIFICATION:BUILDING TYPE _ #BEDROOMS _#BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIIFP #SEATS, :L IND STRIAE WASTE Yes or NR
:LOT.SIZE '_.TYPE WATER SUPPLY ` �' DESIGNWASTEWATER FLOW(GPD) NEW SITE' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. .TRENCH WIDTH ROCK DEPTH /�r' L'}NEAR Fr.. '
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
jWl". vp W FIE' g'ik +BRIBER t ) IF 6491 B&ON PINIMED_ BRM*. ,
A .
"CONTACT A'REPRESE.NTATIVE 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(7ftftx
OPERATION PERMIT
SYSTEM INSTALLED BY: \
fs
AUTHORIZATION NO., !'�OPERATION PERM�Y.
ATE. O
"'THE ISSUANCE OF THIS OPERATION PERMIT SHALL][NDICATE THAT Tl[](E SY D ABOV HAS EN INS
T'LLED IN COMPLIANCE
WITH.ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT,AND DISPOSAL SYSTEMS";BUT SHALL IN NOWAY BE TAKEN AS-A,
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD.05/96(Revised)
%
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME //lY -A d1,!114/1✓ PROPERTY ADDRESS ��"h, 1 DATES
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE VOlKi- # BEDROOMS �- # BATHS J # OCCUPANTS GARBAGE DISPOSAL: Yes/tI0
CRCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ,- --
SYSTEM SPECIFICATIONS: TANK SIZE GOAL. PUMP TANK GAL. TRENCH WIDTH _=j % ROCK DEPTH /t' LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
r '
I
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COMITY 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 (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BYCG*./
-70
A
I
I
AUTHORIZATION NO. OPERATION PERMIT BY DATE Qb6 A�
**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.
nrun to/os
. ti
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APP ICATION FOR IMPROVEMENT PERMIT(REPAIR) M
NAME 1 PHONE NUMBER
0'/
ADDRESS12Y& �l `� B IV ON NAME \
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED �2_&NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 7- NUMBER BEDROOMS NUMBER PEOPLE SERVED
O
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
L
DATE REQUESTED INFORMATION TAKEN BY
This 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 this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93
a