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A,JT,HORIZATION.ivo: >i 6-ADAVIE COUNTY HEALTH DEPARTMENT P� 3 0
Enviro mental Health Section PROPERTY INFORMATION
Permittee's `7�s 4 �% r,",1 P.fl/Box$48
Name: ', i' 1/J L4/ i �+�► G`✓..f %/ ocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760'
Directions to property: / ' ." 71 Section:` Lot:
J} AUTHORIZATION FOR
WASTEWATER Tax Office PIN*
SYSTEM CONSTRUCTION
Road Name: Zip}
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any.Building-Permits;This Form/Authorization Number should be presented to the Davie County Building Inspections
Office whenapplying for Permits. -
(In'compliance with Article I 1 of G.S.Chapter:I 30A;Wastewater Systems Section.1900 Sewage Treatment and Disposal,Systems)
/' , , / L/ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
1 IS VALID FOR PERIOD OF FIVE YEARS:
ENVIRONMENTAL HEALTH SPE IA I$T. DATE ISSUED
9 6 ;3DAVIE COUNTY HEALTH DEPARTMENT P� " 3 0 �' 2
yy
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
•+ 13ermittee's ,
Name: '`" r e. . ,.;.,,, .41 Lv_S' Subdivision Name:
Directions to property: ,?If,/, Section: Lot:
IMPROVEMENT
IxPERMIT Tax Office PIN:# _
J 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)
1 . .
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�^ 3 ,i PLANS ORTHEINTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST . DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE �/7[ #BEDROOMS � _#BATHS ` _#OCCUPANTS _GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPES #PEOPLE. #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY '/ e DESIGN WASTEWATER FLOW(GPD) L') NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `9 ROCK DEPTH 1p2�LINEAR FT Ma
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*APPROti
UENT_FILTER* RISER(S) IF 699 BELAY) FINISHED GRADE*
77E
I
**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
OPERATION PERMIT
/ SYSTEM INSTALLED BY: Uf/
- r
AUTHORIZATION NO. OPERATION PERMIT BY DATE:L__z
**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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
1 APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) (ate
NAME PHONE NUMBER 1
ADDRESS Jam- �w -�°-`/ auz , SUBDIVISION NAME
Lo -- S2
t:— / c7 LOT# >
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING r1,�
1
DATE REQUESTED Z a 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
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