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y AUTHORIZATION NO: J DAVIE'COUNTY'HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittees" l/ P.O. Box 848
ti Name: I(/l Ivlocksville,'IVC 27028 Subdivision Name:
/� Phone# 336-751-8760
Directions to property:;!! Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# - -
t ►' J�'a v'v!,/S�'.,� 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-Penn iis.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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
G .... / IS VALID,FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST ;DATE ISSUED
�.�-� �-"Y" `I` � "r•»-�_ l�k,� ,i' �: `,�'.:, � t'F:^>� 'Y"v`n=;� !,.; r f �.c` rt*t,;,v>�`r r. r s.,-..,.���,,�..i. y.
may. p6t -15-7d�
DAVIE.COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Subdivision Name:
pirections to property: r. t' '"F; /� Section: Lot:
IMPROVEMENT
PERMIT f Tax Office PIN:#
�" .j f,•',: f F ,J (':.�'� r �� �. Road Name: Zip: 0
**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 GS.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
e,f 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 _#BATHS e2 #OCCUPANTS�'��GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD), NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH \f�K ROCK DEPTH-7Y LINEAR
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER* *RISER(S) Ih= 61' BELOW FINISHED GRADE*.
G�
deo
��ra
JAI li
**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(70M Bad)WWX X
(336)751-8760
OPERATION PERMIT ,
SYSTEM INSTALLED BY:
G(/w
1
AUTHORIZATION NO. OPERATION PERMIT.BY: DATE:
a "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) M
NAME PHONE NUMBER T_
a �x // °
ADDRESS SUBDIVISION NAME (�
��C�.0��Cf/t��-e�• l. C LOT # , U
DIRECTIONS TO SITE
T A
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
�J
DATE REQUESTED INFORMATION TAKEN BY '� v
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.1193