1583 Liberty Church Rd (2) yolk:y., r *'q.r ....cwt Z,A'.wain+t s.�.:+1 ,E�r->.r+.4 'r r'Y3 ti-•':.fir •'YotalY -t`r c-...'✓:.x•^i -'. .�t.. l Y'kl�' �i��:'r.`x s&'.,�avr .f-iu:.'�V.sr�'1Gtv�.'�
i AUTHORIZATION.No: ., •. .DAVIE COUNTY.HEALTH DEPARTMENT - E
Environmental Health Section PROPERTY INFORMATION
Permittees ff P.O. Box 848
Name:' /'
Lp� / Mocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760
~Directions to property: ✓ Section: Lot:
AUTHORIZATION FOR
Q �o, N {. _ WASTEWATER Tax Office PIN:# - -
'
/)SYSTEM CONSTRUCTION
v%W�� Road Name:L• el.�1t,P Zip L2oZY
:**NOTE**This Authtiization for Was ter 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 theDavie County Building Inspections
Office when applying for Building Permits. ;
(In compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f ./G? IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUE
!' .T'y 'm. ,! --•--4 v-- - .ter-"'- '`'iT� is .M ..-.-.r = _ .� :t :,� �rt .J
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATIOV
P�rtmttee`s
r Subdivision Name:
DireSrions to property: 4 ..~.-...r f Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - ' -
(' v i/ ""� Road Name: t,t, Zi 2,7 67 P.
` **NOTE**This Improvement Permit DOES NOT authorize the constnlction or installation of a septic tank system or any wastewater system.An
'AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION trust be obtained from this,Pgpartment prior to the
construction/mstallation of a system or the issuance of a building permit. r
(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 }
W"f" w` PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER.,
',ENVIRONMENTAL HEALTH SPIICIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TIM PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS _#BATHS ,_#OCCUPANTS GARBAGE DISPOSAL Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
IAT SIZE ,TYPE WATER SUPPLY G DESIGN WASTEWATER FLOW(GPD)-v,/ NEW SITE • REPAIR SITE+
A, SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH / LINEAR
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT EFFLUENTzFILTER* *RISER(S) IF 610 D11.014 FINISHED GRADE*
�► �� R12-
L-�,J vA,L\)
Y.hD0� Sa l
6j Cl
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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(70)t)684 9Z(X X
(336)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY:,---'C�� �/lllfh��I/L
AUTHORIZATION NO.---���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)
A
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME A L` q 44/ PHONE NUMBER
ADDRESS_?2yPOiyo�,/�l' SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
�. Z
TYPE FACILITY_ XA&A.LAW) NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY 4VE& SPECIFY PROBLEM OCCURRING
DATE REQUESTED /d { INFORMATION TAKEN BY
f
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
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