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7502 Hwy 801S.,. v -,..i fxir'.. a. .rs; : .-- .. ,., .�.` .,,, ... ., a ,w „ .., n , ;la, ,, rF , ;-s'k``+...,. •'�... l.•{,, s;,,. -ars, .fit, Ie.�... ,., ,.i, ,X,, -q, :y� /L i' Permittee's DAVIE COUNTY HEALTH DEPARTMENT �Ocv 616� 'lame`ee �r� /1/t�,A/)loGtrAi Environmental Health Section PROPERTY INFORMATION a } f��t J• fG�YttIlt�dt�� P.O. Box 848 Directions to property: / Mocksville, NC 27028 Subdivision Name: It'll l' ij,%' �S . ty, llouesc '61V % 01 Phone #: 336-751-8760 Section: Lot: Albdla(,I� jAUTHORIZATION FOR rl led. WASTEWATER - SYSTEM CONSTRUCTION Tax Office PIN:# AUTHORIZATION NO: 002753 A Rad Name: k **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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) + ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION –6,-07 , IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE SF hoBEDROOMS q # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No O c-t� c - LOT SIZE 1� $l TYPE WATER SUPPLY _W'" DESIGN WASTEWATER FLOW (GPD) tt g 0 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE X`�IVAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 3G O OTHER 4Zemo�Q--tt_ep . . Giu I�h� zoYn S-ep . c : H e�•5 r e a.r �k� y REQUIRED SITE MODIFICATIONS/CONDITIONS: AcAA 3©6' c-4 rrc1C,;aic-,n aW / .SL%•J(ctoU E'. 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 PERMITa e ?. YSTEM INSTALLED BY: �� � (�U � Ph e, IL.– IL.–G/K_. i C PC, Lee �rUctsy,1 R" v 4 Itoa / ININ N�. $4 i AUTHORIZATION NO. G �2'2�OPERATION PERMIT BY: DATE: J —2 *"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 (Revised) . .aMlff ✓Zl ;;q :..:.; ., �. ..A .,. "f»< .. }4••'"+" ....>. „i..r„ ..•.'r:r,. .h+ ''M.. _ • `r. ,. 6 .?.;�ti•i,r.-d�",,,c,i.. « a�-• w'.r"rr +'.Sp. 1,,., d:.^...••,tertL,t;..;:ar..+. Z•wa.�,�4 -..r, Permittee s ; r 1 DAVIE COUNTY HEALTH DEPARTMENT a/02 Environmental 'Health Section PROPERTY INFORMATION --'' P.O. Box 848 Dlrections`to roe 17(ja• �L#i `1:1 i��t (;�.� p p rry: Mocksville, NC 27028 Subdivisiorl,Name: fI Phone #: 336-751-8760 Section: Lot: � I � t:: � j� / , �,i , 1 • ' r �i ;ct ,'' e j � � +z a - + t r AUTHORIZATION FOR / f ,� /1 WASTEWATER / � !� �, r -i I!/ F `L SYSTEM CONSTRUCTION y Tax Office �PrIN:# a `lrJUd�+ It J�tti1J !f� AUTHORIZATION NO: 002753 : A 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 Office when applying for Building Permits. O (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems) ***NOTIICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE 5F IBEDROOMS _ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No 1 I ct TYPE WATER SUPPLY lr r LOT SIZE DESIGN WASTEWATER FLOW (GPD) 4 NEW SITE REPAIR SITE i-' SYSTEM SPECIFICATIONS: TANK SIZE C X�Cr�AL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 36o OTHER (� P,F0%QI(c�I-�5tr'7.G REQUIRED SITE MODIFICATIONS/CONDITIONS: A,14 30c' { . { r'r lCl t •t , L., H < L j .5 .'� r t.� , ` "c tin ( Ll IMPROVEMENT PERMIT LAYOUT �u5t b -c '3'Q IG/ ._.. �l eta \\Sa � 3� ''a� ._ �.� '4—^•—��f c„� r� �bin !; 1 A�,p�l ,..�r' JF*µ[. �• 1'" Y 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 C G FCYST M INSTALLED BY: _ cam..i ruas� . �zah ►S= r�'` Ro�� d��y� 3 5W i AUTHORIZATION NO. 2 / OPERATION PERMIT BY: i DATE: —2 **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 U�EATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNC'T'ION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD07/02(Revised)„ll�.r yZ3Z ..: Uo�� ..�y -, \. . -- + DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION i APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) 4 [�� NAME �.��,�i /Y!l Cl6l9/�cyS�U PHONE NUMBER AV- 6395' ADDRESS -K61, W #WV 9'01S �OCKJ l�� �l� `"C SUB IVISION NAME LOT # DIRECTIONS TO SITE d, ,S (illi' DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER " Z sidi?_q l%6/ urpveti trouq h I q 36 TYPE FACILITY a NUMBER BEDROOMS- NUMBER PEOPLE SEINED - TYPE WATER SUPPLY_W SPECIFY PROBLEM OCCURRING �Un7I.r Y " Z/Z7/U % Aqaqxa1&-7L ; [,!/r1-JPr / H/ '6Rg1 _ (1*12d. DATE REQUESTED? "y7 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. ,199 ACcT fm 1 u> ►.tel` � «r ., sa ti y _ y h w � A. v w _ r � x .a TF-7. • •. ,^�:.�, :,� �� � "hy „'raj' . l i' ' t