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236 Bailey Rd y,a i.i Id ..��ri``lY o� C•d'�:dJ,�L:RfiM jn' ',." Yv:SnS r4 1')'. 7"�i.r�'$ 1 .:Iri�l`I'6 .i � z .. < . .. _ � ,. ':., AUTHoJZIZATION NO: 0956 DAVIE COUNTY HEALTH DEPARTMENT © ✓X6 ~ • Environmental Health Section PROPERTY INFORMATION Permittee'S � P.O.Box 848 Name: Mocksville,NC 27028 Subdivision Name: Phone#:704-634-8760 Directions to property:ZiAPIA Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - Road Name: - Zip: 0406 **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) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED kw�^.fb�Y�'i F ��#'4vYFa+ ' �k"ir�Y¢ At' f�$�kr'xnkij; ri�rx` vel"d"wed?wii`(�FIAi, �ik'y4^a''tv"irT vPklr �4'3'�p� lay^f�°rifz✓Y'�Y'Ss�" ryXJ`°�'t �:°��'" '�� DA VIE COUNTY HEALTH DEPARTMENT '`= f IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee's Name: A le J;40-e76- Subdivision Name: Directions to property: AcL Section: Lot: - IMPROVEMENT PERMIT Tax Office PIN:# Road Name: �- Zip: **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 +rt' [r §� -' ce". ° - ✓,i' PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE J. INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE_/rar #BEDROOMS _#BATHS_�#OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY ZV(-& DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH _ LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 0 r"0`'`� s **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 SYSTEM INSTALLED BY: AUTHORIZATION NO.-- OPERATION PERMIT BY: DATE: Ze&l **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 NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96(Revised) Sys .rfti�•q a-*-e,..4s:'^..: �S>+.=;ti . p r"'"':°` ; 7vv-3""'c.9w,.�.y.A S .�.,�+. `r i:a `��f•`e%'N° +;3",i" �'-•`+ ti "'t1 w�+a".v, .-�', ;,.y..,.:r_r..St •. v r:-"+'•.•_z'r r>%w,,. t'* , " DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee's Narde: i ':G'Ae Subdivision Name: Directions to property:« Q _ Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name: '--L• Zip: 00� **NOTE**This Improvement Permit DOES NOT authorize the constriction 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 j ,/ ,- "t s, S`e '' ;r'' :%` 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 4V #BEDR00+S #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No , COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #'PEOPLE/SHIFr #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY /lJF DESIGN WASPWATER FLOW(GPD),tl,�, i" NEW SITE ,REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK +GAL. TRENCH WIDTH ROCK DEPTH LINEARFT. ��l REQUIRED SITE MODIFICATIONS%CONDITIPNSM� IMPROVEMENT PERMIT LAYOUT i r C7 Ive ll **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 SYSTEM INSTALLED BY: v~. Sao AUTHORIZATION NO.---�1�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) x DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION a eh 1 APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)}' NAME 4c1 4� _ Sh ee-+ PHONE NUMBER C ADDRESS D d 2r SUBDIVISION NAME A0&5V1#C'OT # DIRECTIONS TO SITE n= Aj t&LLt-Ce- �kacks- r ::'�r Ir-f, D d DATE SYSTEM INSTALLED ?NAME SYSTEM INSTALKEng� 2067~'g TYPE FACILITY NUMBER BEDROOMS /o'?-oINUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING AREQUESTED 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.1/93