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AUJTHORIZATION NO: 0630 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION ,
Permittee s, P.O:Box 848 ,
Name: ��+�4 A Mocksville,NC 27028 Subdivision Name:
Directions toproperty: L5 Z Phone#:704-634-8760
: Section: Lot•.
AUTHORIZATION FOR
. WASTEWATER Tax Office.PIN:#
SYSTEM CONSTRUCTION
Road Name: VSX�Nz -ft- �kli 7
r p..
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmentaf Health Section prior
to issuance of anytBuilding Permits,This Form/Authoniation Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits:
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
Q ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
. / IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
l
q.v.ylz.
DAVIE COUNTY HEALTH DEPARTMENT.,
IMPROVEMENT AND OPERATION PERMITS PROPERTY'INFORMATION
PeiWit e.
N e' "• �a t p -' Subdivision Name:
i4ecti®ns toproperty:
°- Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#' _
Road Name: - .t. rte,x,,a.:"�dip: 1I` :`t
**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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
v *r+ t* ��r,.✓ ' 3 t - 9 PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE '
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE , -�)L #BEDROOMS--,5 _#BATHS #OCCUPANTS_ GARBAGE DISPOSAL:Yes oU
COMMERCIAL SPECIFICATION: FACILITY TYPE? #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE;Yes or No
At
LOT SIZETYPE WATER SUPPLY �v DESIGN WASTEWATER FLOW(GPD) J NEW SITE E REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 10 O b GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH I O LINEAR FT.J
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
_t w
IMPROVEMENT PERMIT LAYOUT
F
.� o vs �
f
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTf?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 INST LED
11 10 DATE
AUTHORIZATION NO. OPERATION PERMIT BY: DATE..
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
r ' 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.,
DCHD 05/96(Revised)
i
, 'Y,i•'P> it#� �4 ^k4Y
• y;;a 't% DAVIE COUNTY HEALTH DEPARTMENT
%*;a
r . , IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
�. Pe
Subdivision Name:
Directions to property: 1' fi Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name:---,. �.:. Zip N:'t
Mt /
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE OD.; #BEDROOMS.% #BATHS -' #OCCUPANTS GARBAGE DISPOSAL:Yes o `.N-9 i
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE::Yes or No
rr \ '
LOT SIZE t ' =¢'' TYPE WATER SUPPLY �l J C s' DESIGN WASTEWATER FLOW(GPD) 1 NEW SITE REPAIR SITE
jp11
SYSTEM SPECIFICATIONS: TANK SIZE 0 GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1 C LINEAR Fr.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
RAPROVEMENT PERMIT LAYOUT -
Y
h j+
f
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTI-t 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 INST LED
(I D rl 0
1
AUTHORIZATION NO. OPERATION PERMIT BY: DATE. /
**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.
DCHD 05/96(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) Q
NAME V3 tJ VA S Q a S PHONE NUMBER
ADDRESS �J F�Ryr SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY o vs a NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Vim' SPECIFY PROBLEM OCCURRING
DATE REQUESTED 5 17 INFORMATION TAKEN BY Czl�
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am response le for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/83