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` Permittee's ,,� ,,,�` DAVIE COUNTY HEALTH DEPARTMENT � �' �' ✓� 7� �S
�,�;�1�er �� a �.,���'If'+'' Environmental Health Section PROPERTY INFORMA N.
/ , J P.O.Box 848 �C. / r—
Directions to property:'� y -�"� A +�`�� � Mocksville,NC 27028 Subdivision Name: �i Z S
��„-,r ,�'�, a. :-�' y - � - Phone#: 336-751=8760 ,
f"�",r''�• �F=' f1��.��� ,.y,��/ . t"r,��%•a'�� : Section: _ LoL•
,• ,� AUTHORIZATION FOR
',+;�-• f ��'►� WASTEWATER Tax Office PIN:# - -
SYSTF,M CONSTRUCTION
AUTHORIZATION NO: ���� p . `` Road Name: Zip:
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
� to issuance of any Building Permits:7fiis Form7Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pennits.
; (ln compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section,1900 Sewage Treatment and Disposal Systems)
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� %f�,,�` ;'�,� f•� �' �rR ` c.,.. ***NOTICE***�TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION �
f i ft''��r``� l r�''; ' ' '�� IS VALID FOR A PERIOD OF FIVE YEARS. ,
ENVIRONMENT L HEALTH SPECIALIST- DATE ISSUED_
P E '. �' # Mn ���l�A #O PAN '
RESIDENfIAL S ECIFICATION:BUILDING TYP BEllR00 B THS CCU TS GARBAGE DISPOSAL:Yes or No
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COM�vIERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFf #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)-����F�'.EW SITE REPAIR SITE I�!
,
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. .TRENCH WIDTH�.,�,,,����ROCK DEPTH � �+ L NEAR FT.�
OTHER , :
' REQUIRED SITE MODIFICATIONS/CONDITIONS: � r� '
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IMPROVEMENT PERMIT LAYOUT . S � - .
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.�OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. , ' "
OPERATION PERMIT '- �
SYSTEM INSTALLED BY: � �( r��
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AUTHORIZATION NO. PERATION PERMIT BY: DATE:
+'THE ISSLJANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE-
WITH ARTICLE I 1 OF G.S.CHAP'TER 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. .
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�� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ���
. �" APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �
NAME /G'� PHONE NUMBER ,�'�� �oG�,���I
' ADDRESS � � � � � SUBDIVISION NAME
�� ^ /� � � LOT #
DIRECTIONS TO SITE � ` - � v� r'1 � �`�� .9 �
DATE SYSTEM INSTALLED--/'�� J� NAME SYSTEM INSTALLED UNDER
TYPE FACILITY " NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ��SPECIFY PROBLEM OCCURRING
�
DATE REQUESTED INFORMATION TAKEN BY � �t
This is!o certity that the iniormation provided is correct to the best of my knowledge,and that I undereland I em responsible}or all chargea incurred from this applicadon.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.,/93