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AUTHORIZATION NO: `� 8 9 34 DAVIE COUNTY HEALTH DEPARTMENT
• ,. Environmental Health Section ~ PROPERTY INFORMATION
Permittee ti - /A� I- P,O.Box 848.
Name: Mocksville,NC 27028 Subdivision Name:
/ f y Phone#;336-751=8760
Directions to property: /�/ (5 r r/ /� Section: Lot:
AUTHORIZATION FOR
SYSTEM CONSTRUCTION Tax Office PIN:# q bn
Road Name:GSW zip:210 ?-d'
**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
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)
S .3/ NOTICE THISAUTHORIZATION FOR WASTEWATER CONSTRUCTION
S VALID OR A
PERIOD OF FIVE YEARS.
E IRON ENTAL HEALTH SPECIALIST,.,: DATE ISSUED
'✓.:'{ze:B'' 'Fj/^'-�T`-+''Tc;r' 3'a�'t''�t'-^y7`-riJ a•.yui,r-.Y`�+a+i.'k�" "4. � e; .rr,�,.,l..M?yI rn. Y, :i :. _ .� r._ _ ` -.. _.
9 ► DAVIE.COUNTY HEALTH D TMENT /'('�J c� -1
IMPROVEMENT AND OPERATION P ITS PROPERTY INFORMATION '
;'Permittee�s���~~''�
Name`` f rlli7J`!( Fia/NJ�n�' S division Name:
'Dectresns-moo property: Sec 'on: Lot:
IMPROVEMENT -
;r PERMIT Tax ffice PIN:#j G U_ E
Road Name: zip:2-7e, Zd'
**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
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
EAVIkCrA4ENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM. -
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY.TYP
#PEOPLE #PEOPLEISHIFT—_,,_/ #SEA'L'S INDUSTRIAL WASTE:Yes (,:No)
LOT SIZE TYPE WATER SUPPLY l DESIGN WASTEWATER FLOW(GPD- �C� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�U� ROCK DEPTH LINEAR FT. ;Oe)
41
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVGRAD
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF TH ISTEM
C(�,
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS
(336)75-$760
OPERATION PERMIT
SYSTEM INSTALLED BY:
ti
AUTHORIZATION NO. � OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
j _
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
�+^• �._r APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME f w% ac AK4rv%Ar*-c zyk%-� PHONE NUMBER 7SI- 3372
ADDRESS NO LU "y 64 LUt4 T' SUBDIVISION NAME
VYk,w Lkdv'.1 Lt YN L 2,7a)2,r LOT# �p
DIRECTIONS TO SITE `�w" r/'^ `!�'�' � '>~. X-`�° N
rl
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER �j
TYPE FACILITY SI,. NUMBER BEDROOMS_ OVA NUMBER PEOPLE SERVED � C
TYPE WATER SUPPLYSPECIFY PROBLEM OCCURRING
0�.
DATE REQUESTED INFORMATION TAKEN BY
0
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application. N$
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.t/93