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AUTHORIZATION NO: 0852 DAVIE COUNTY HEALTH DEPARTMENT;�, •�''o .
4 Environmental Health Section PROPERTY INFORMATION
Permittee _ P.O.Box 848 /'--
Name:.
- r, STs
Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directioris'to property: sr. ' Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# _
SYSTEM CONSTRUCTION
Road �lo �% ` �•: .1.t. Zip: 1 DAG
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie Country Building Inspections
Office when applying for Building Permits.-
(In
ermits;(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal`Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.`;” 7 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
1
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
P�rjntle ' ,
, ,Name: Subdivision Name:
Directions to property: Section: Lot:
IMPROVEMENT
�; ^�; -► ; PERMIT Tax Office PIN1 -
Road Name
**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)
I.I
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
w ! } 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} #BEDROOMS 'D- #BATHS #OCCUPANTS 5 GARBAGE pISPOSAL:Yes of o
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE Yes`or No
WT SIZE c TYPE WATER SUPPLY W^ DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH J ROCK DEPTH W LINEAR FT. a 0 y-
OTHER
REQUIRED SITE MODIFICA'T'IONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
L
r y
*"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(704)634-8760.
OPERATION PERMIT �A NrJ` ��-}►TA���
SYSTEM INSTALLED BY:
Y
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AUTHORIZATION NO. bZ OPERATION PERMIT BY: DATE: ` 1�
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE STE 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)
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- ,;.• DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION/
Name: - < ,� ; Subdivision Name:
Directions to property: 4 ! Section: Lot:
DIIPROVEMENT
PERMIT _
Tax Office PIN:#
Road Name Zip: t f
**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
{ '4 PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE T IIS PERMIT BEFORE
INSTALLING THE SYSTEM. +,
RESIDENTIAL SPECIFICATION:BUILDING TYPE "--� #BEDROOMS '.1 #BATHS 1 #OCCUPANTS GARBAG -,DISPOSAL:Yes or`
7.
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE'<(•.e=,�-c. 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. Uy
OTHER
1
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUTS
r ,
� t:1 ��
**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(704)634-8760.
OPERATION PERMIT A N!_V Y`•,
SYSTEM INSTALLED BY: LA)
Yet A IQor
150
Ty
13
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AUTHORIZATION NO. "S?, OPERATION PERMIT BY:—,-(
DATE: J�
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE YSTE 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)
f
` DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) L
NAME PHONE NUMBER cm
ADDRESS `�o� ` SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE �.�
DATE SYSTEM INSTALLED �� 1O�' NAME SYSTEM INSTALLED UNDER
TYPE FACILITY \�L NUMBER BEDROOMS 111 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY W SPECIFY PROBLEM OCCURRING
DATE REQUESTED }J 1 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 Ce L
Rev.1193