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136 Legion Hut RdP?mittee' ,n DAVIE COUNTY HEALTH DEPARTMENT Aam �{�t! i e ': '� Environmental Health Section PROPERTY INFORMATION _ "`P.O: Box 848 Directions to property: o') to �� � �'�`�Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: (' AUTHORIZATION FOR - F�Y. S �s-T t7t� WASTEWATER I)�1 Tax Office PIN:# --r-r—� SYSTEM CONSTRUCTION 112 AUTHORIZATION NO: A _ . Road Name: p: **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 w'slt Arti 1 1 I of , .S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION LnL IS VALIDFOR A PERIOD OF FIVE YEARS. M ALTH SPECIALIST -—DATE ISS ED RESIDENTIAL SPECIFICATION: BUILDING TYPE.IOMF # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY T(Y�P;�E'�,`�-�/ # PEOPLE # PEOPLE/SHIFT! # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE � r ECTYPE WATER SUPPLY`f"N 1 DESIGN WASTEWATER FLOW (GPD) NEW S REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH R K D PTH Z LINEAR FT. OTHER ' ! itG�30 X r;,REQUIRED SITE MODIFICATIONS/CONDITIONS: 6 IMPROVEMENT PERMIT LAYOUT :ZLI ►ams $- X 1J,A�;D T-0t-3D&'W AA,, vJ tit 1 ,_3 ,; <<!Lo T � Neo b- Igo 1-}0wv .1`^� I0©3 00C . 2 1'11-34> `r0TAL L,7J(,;T1+ 134t **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(336)751-8760. DCHD 02102 (xev;seQ DATE: Lo -3 A V EEN I TAL LED IN COMPLIANCE B T AL IN NO WAY BE TAKEN AS A TIME. 4 DCHD 02102 (xev;seQ DATE: Lo -3 A V EEN I TAL LED IN COMPLIANCE B T AL IN NO WAY BE TAKEN AS A TIME. i y "DAME COUNTY HEALTH BE1�ARTMEN . , Environmental Health Section PO Box 848/210 Hospital Street Al Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT a REMODELING o RECONNECTION ❑ �^ �-- 33G -��y�� Name: e r ti t t'o T� r t { Phone Number: 6aS _(Home) Mailing Address: / 3 L P� , o r �{� % Cl - Ce //4 3A, 6 S a i 96 Y (Work) Detailed 'Directions To Site: WWI � O/ I /w,' e t 1�1,ok gu4 121 on IPF WP or -r 4141,411 on Property Address: /3 6 1Fa,n„ 144 /fid } Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: V n n O, 1 a 0 a y\ Type Of Dwelling:_5 Date System Installed(Month/Day/Year): 5 74 Number Of Bedrooms: 3 Number Of People - Is The Dwelling Currently Vacant? Yes ❑ No Z' If Yes, For How Long? Any Known Problems? Yes ❑ No/ If Yes, Explain: Please Fill In The Following Information About The New Dwelling'. Type Of Dwelling: / Number Of Bedrooms: Lq Number Of People: .5 Requested BY Date Requested: ±jn bi.C.,VL R_L V,;j Y (Por)'Environmental Health Office Use Only APProvei "' Di6ov6i' p� �C_ r4h-1 r tsSL,t 16 !-12olt� y -o` ,t�7NL4�2&4 Comments: Environmental Health Specialist ` Date .w *The signing of this form by the EnvironmentaU ealth Staff is in no way intended, nor should be taken as a guarantee(extended or limited) theon-`bite wastewater system will function properly for any given period of time. o O'�--- Payment: Cash ❑ Chec oney Order I Z; / , ? ` 4 Paid By: r- Received B Account #: Inv, C> o a ` �` Invo ce #: L1.1'.,ji( 3 J t ,� i . i. f 06 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a �%r��ry _kSanita�ar�✓✓ Permit Number Name .2 Date I/ % 4;1 N2 77 �J Location /[ �it� —� i1 �t'%l'�✓� Subdivision Name Lot No. Sec. or Block No. Lot Size �lIG _ House Mobile Home — Business _.— Industry No. Bedrooms C;-2 _.No. Baths __L— No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer YES �NO ❑ a/ J a Auto Wash Ma thine YES NO ❑ ��%�"'� Type Water Supply 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. i - j i i i Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by /a OP�Lh � Certificate of Completion _"G Date -Pl �`vIr 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function .... :,.t.. i.Inril"r inr nnv n •,nn norinel of firm ,�. ��-� ti41 �„ � '� . a � , „ ` � ; � r �� " , , i/i.=,; -r .� i � �� l� �'7�`y &' �„ _ � . ,. /,,. � 1� �s �, � q t��. \ �S� l`- � • >, � �- � � '� � *�yy - �,�j �. ���aj__� @ �� i oi � � '�'' ��� �� �a � e�y 3�y� �s� � � - 1�O aY B5 --, � �� Z � PilZ � - a �� �``"� �f' ���.� �' �� t � *, �m a�� „� / �r � �`"� ���� ` ���� s �� � �� , � �^ y ,�� � ' z� �����a. ` ' ��. ���;i \'a y", ' �'"� �� � , � � ��. , �� ' � ' � ii ��� � ��,s ,, ` ; �� � a a.. ; P � / j �� 1�� ,� � ��.� ��� A F i,. � it "� 1.. �. � �� �l ��/ i A _ �e ' ��n��„, � � s� 3 � /i //; r/ / ,;.0, ��\ `~M�s.� �F ��� '� �6304 �, �- �, �_� ���qt ��a � .. � �� � %, , ,,,,- , ii� i� ��a ��*� ��, < r'� � `h,���� � �k*s`� �,�� 215 � , ti � ` �`' i �i,.,,�. 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