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_,XUTF ibRIZATION NO. � �� C� DAVIE COUNTY HEALTH DEPARTMENT
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Environmental Health Section - 'PROPERTY INFORM�ATIO�I�T" � ...,.
� Permittee's�` P.O.Box 848 ��'CO ��. '
` Name: _ '$o� ' ' � Mocksville,NC 27028 Subdivision Name:
' Pfione#:704-634-8760
Directions to property: '�-��,"� t ��"►s� '�G41'� , Section: ` Lot:
` AUTHORIZATION FOR
�il2r� i-.�o �(Z.r% �"'tts,"�1:r*.1 � �v WASTEWATER Tax Office PIN:# _ _ ' i
{T SYSTEM CONSTRUCT'ION '�� ,
(.)/��c�L(��15� �.. o ���;..3 C�it� Y'�" � �..�%�T RoadName: �f-+Y� 't70��ip: �'L� �:+t�� fi
' **NOTE**This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Sec6on prior
to issuance of any Building Pernuts.This Forn�/Authorization Number should be presented to theDavie County Building Inspecdons
: Office when applying for Building Permits. . , .
(In comphance with Article 11 of G.S.Chapter 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,
a-_,...,,,,, f_ j -
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� '�� " ' ` ' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,
' � , � ,.,,,P ' IS VALID FOR A PERIOD OF FIVE YEARS.
ENV RQN HEALTH S .ECI L T DA ISS ' � ,
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""� �",;�_ :-,-<-+'r� IMPROVEMENT AND OPERATI N PI�RIYII�'�_.. �ROPERTy INFORMATION -��• ' �
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� ::N'ame: ""' � ��;;:e,.3 � � 1.-,��`"�� s Subdivision Name: r
;' � Directions to property: ��q.�. � �'p'=� "'+�° ��>"°-�`��; Section• � Lot:
� Ilb11PROVEMENT
�1�,:�:,,'� �. �� ��ri:� ►. 2'-,:"�,.c� M� Tax Office PIN:# '
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� � 4 ��:: PERMIT - -
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���'�,+� c:��.��.�->�'�, �. l��:, #'�,s,;, � c`.�. ..� .,� K�r,,� t,,.c, � Road Name: ���'...51 ��cS����Zip:�.. .��rn:.r�,:..
:
**NOTE**This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATTON FOR WASTEWATER SYSTEM CONSTRUC"TION must be obtained from this Department prior to the
! construction/insfallation of a system or the issuance of a building pernut.
;,
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Sec6on.1900 Sewage Treatment and Disposal Systems) -
I . : �Y'.;E +""�'*i. f`��"'TM~"" �,/° ***NOTICE***THLS PERNIIT IS SUBJECT TO REVOCATION IF SITE
j '` .., #;1 , �� ,� r:r ,'�` "`, /� >_�.�"� ,.H^j PLANS OR TAE IIVT�NAED USE CHANGE.YOUR WASTEWATER
, � ENYIRON���NTt�.�"HEALTH SPECIALIST DA ISSUED 5YSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
� �r' . INSTALLING THE SYSTEM. ""
�... �_
� RESIDENTIAL SPECIFICATION:BUILDING TYPE ��� #BEDROOMS � #BATHS ' � #OCCUPANTS�GARBAGE DISPOSAL:Yes or !o
i' ' ~.U�
COMMERCIAL SPECIFICAT'ION: FACILITY.TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No�
.
'�, LOT S1ZE '� ���Y'TYPE WATER SUPPLY�l�a� DESIGN WASTEWATER FLOW(GPD)�� NEW SITE REPAIR SITE •�""'�'�'
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�i;� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH^-•�'+ ROCK DEPTH +� � LINEAR Ff.��'�--' ';.
OTHER � �i"i'�.•�fif� ��-i�r.,;;� ...w �
REQUIRED�SITEMODIFICATIONS/CONDITIONS: ����'�/.'aLL :� C-�'�'(�'�L , �+'+-�,` �� � �'I.C;>�• t.."M�''P-� r;�`
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IMPROVEMENT PERMIT LAYOUT �� ; . ' ``t�-
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTIOI3 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.
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OPERATION PERMIT �� j� /_,
�� SYSTEM INSTALLED BY: %A��� w��!A LL.V�
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AUTHORIZATION NO.�_OPERATION PERMIT BY: / DATE: �� �
**THE ISSUANCE OF THIS OPERATION�ERMIT SHALL INDICATE.THAT THE SYS DESCRIBED A HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECITON.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 OS/96(Revised)
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- ,� ��y- �.� DAVIE COUNTY HEALTH DEPARTMENT- -_- .- ,.,,.-�,� �n;3�r '
""`°" �"'�-- -� �-�.:,=-` �' 'IMPROVEMENT AND OPERATI N PERMITS PROPERTY INFORMATION '�-���.
,'�ermiftee.'�:`�`�.�"_._: �� . : �'O �-
� ..,,...N�me: '' . ��'�'�. �€:�'..,:.,,,-��r� Subdivision Name:
„ .., �
�. �Directions to property: ���>+ � �'�'' "���: ���=#� Section: Lot:
Il14PROVEMENT
, .,._1 v�ir.,,.'� ��p �t�.?� '�`:::';t•.,"'t'�:,�.,.? f�, j�s : PERNIIT Tax OffiCe PIN:# _ i
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l.)t�a�'c:��ti�".��� L..�r� i4�,;,"'� l��:�.,i�� ��"E7' c""'� �,,,.�::.£`t Road N�e: ��.�'t� ������'Zip:����t�"�
**NOTE**This Improvement Pernut DOFS NOT authorize the construc6on or installation of a septic tank system or any wastewater system.An
AiTfHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
� , construction/'installation of a system or the issuance of a building pemut =
(In comphance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,;
,
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' r-��,, "'a �!'""""'""�-..; f +'**NOTICE'�**TI�IIS PERNIIT IS SUBJECT TO REVOCATION IF SITE .
t4,,� �ti, ��, �� �,•^�,�,,^':;' w ,�,.� � PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ,i �
ENVIRON f�I''fC�.�HEALTH SPECIAL 5T DA ISSUED SYSTEM CONTRACTOR MUST SEE TI�IIS PERNIIT BEFORE
��r t..� INSTALLING THE SYSTEM. •.
RESIDENfIAL SPECIFICATION:BUILDING T'YPE� #BEDROOMS � #BATHS �- #OCCUPANTS�GARBAGE DISPOSAL:Yes or�
COMMERCIAL SPECIFTCATION: FACILIT'Y TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
'; LOT SIZE `F�`'-�'TYPE WATER SUPPLY�V�� DESIGN WASTEWATER FLOW(GPD)*��'� NEW SITE REPAIR SITE �+""�'��
. � ,�
� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH��I ROCK DEPTH �z LINEAR FT.�G'�/
. OTHER � �'...�'1�+�3'TI� +.:�s-SCt,�.�
REQUIREDSITEMODIFICATIONS/CONDITIONS: ,��T�.�r. �°'� �`���� . ��- fl� '� i��� �►"4'�'�
IMPROVEMENT PERMIT LAYOUT ��
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**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 �� j� - 1 n
y� SYSTEM INSTALLED BY: %AN�� ��l 1 A�-t3,`
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AUTHORIZATION NO. � d OPERATION PERMIT BY: DATE: �1
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS DESCRIBED A 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 WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OSN6(Revised)
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, � DAVIE COUNTY ENVI�ONMENTAL HEALTH SECTION _
� WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME O 4 PHONE NUMBER �913'oS � 7�
ADDRESS I � I � �J��SUBDIVISION NAME
F1�lv• ��oa � .
SUBDIVISION LOT#
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DIRECTIONS TO SITE ( � �i�� l?-1L-���rf'�X�6��
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DATE SYSTEM INSTALLED � � / 7 7
NAME SYSTEM INSTALLED UNDER ' ��'� ���
SPECIFY PROBLEMS OCCURRING 2!� V�-- �.��S�'�IS
DATE REQUESTED ' - / � INFORMATION TAKEN BY �B�
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