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Permittee s.—�,����� ,�' 't DAVIE COUNTY HEALTH DEPARTMENT �'� .
Name: ��-� � L-'G'�`1"�~� Environmental Health Section PR�PERTY INF�RMATI�N �-
—.; ; , . P.O.Box 84$
Direcdons to property: -�`=�'� � �� �^"�°�'�'*� �"�f ' Mocksville,NC 27028 � Subdivision Name:
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�l/C'J (l.' � t,c. �t"4-k�'�'����—J . Section: _ Lot:
r- AUTHORIZATION FOR
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SYSTF,M CONSTRUCTION �
ALJTHORIZATIONNO: _ `��,�� A RoadName: �t�Cs ��'1.:1:.���'"ZL`ipLc.��.��,�+�y
**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.This Form/Authorization Number should be presented to the Davie County Building Inspections ;
Office when applying for Building Permits,
(ln compl�ian�e v�yith-Art% 1 G.S:Chapter 130A,Wastewater Systems,Section,1900 Sewage Treatment and Disposal Systems)
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,�' � ***NOTICE***;THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
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ENV[RONM H�ALT S IALIST DAT ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE+'WM� #BEDROOMS�#BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No '
LOT SIZE TYPE WATER SUPPLY � DESIGN WASTEWATER FI;OW(GPD)�C..� NEW SITE ' REPAIR SITE �
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH ��- LINEAR FT.2�-�
` OTHER .�- !l�S��L I�v T�Q� ,���
REQUIRED SITE MODIFICATIONS/CONDITIONS: %�r�U'"' � �r��� � ���� I�/ J�✓�"`�
IMPROVEMENT PERMIT LAYOUT '
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**CONTAGTA REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN830-9;30 A.M.OR I:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT > � �
SYSTEM INSTALLED BY: � S' `,`;/
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AUTHORIZATION N0. OPERATION PERMIT BY: DATE: U
• **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANC
' 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. '
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',`��.-� Environmental Health Section "l�� �3`�
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H Phone: (336)751-8760
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-STTE WAS'TBWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING o RECONNECTION ❑
'� Name: ��Zf�/(� �LC/��2 Phone Number: .3•3� (O/�' /(Glo (H )
ome
Mailing Address: �J��o /'YIf��L� '7�/1��' (}��S/� .33�0 7!�" �O�� (Work)
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Detailed Directions To Site:��✓�1 ��� 1✓0�1T1/ 7d �3E,QTl�/ �/,(C/�•�o�9D� T2�✓�� �j,Q,�/ �FT a�/
�E •� OR ,d. '?/�/ vKA( %21' N�` n/TD !3 n/ n/ o•f,�D��J. i-o •9L� E•v�
� � o�✓ E a4 . T �✓ �T o�/i o rY/A�lE 7.t��E�ElluF fI6N.�- Lo��"r �I'6'/.�:
nro�rcy aaar�: l�S(o /yiA,��� T2EE ���✓F, .�dcK�S'���« �►/� a7�`Oa�
Please Fill In The Following Information About The Existing Dwelling:
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Name System Installed Under: l�i,vNET/� L E E �ST��2 Type Of Dwelling:
Date System Installed(Month/Day/Year): /99� Number Of Bedrooms: 3 Number Of People: --3
Ls The Dwelling Currently Vacant? Yes� No❑ If Yes,For How Long? � �a��s �
Any Known Problems?Yes� No� If Yes,Explain:
Please Fill In The Following Inforrnation About The New Dwelling:
Type Of Dwelling: � LL! Number Of Bedrooms:� Number Of People:
Requested By:�"� � / � _ Date Requested: �� �� O
(Signature)
For Environmental Health Office Use Only
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Approved ❑ Disapproved ❑ � ��y
Comments: ��� ,�'i`� !�-� �� �� i ��U�'�'t ��Z.4�[�i.�
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Environmental Health Specialist Date
"''The signing of this form by the Environmental ealth Staff is in no way intended,nor should be taken as a
guarantee(extended or limited that the on-site wastewater system will function properly for any given period of time.
����aymen� Cash❑ Check Money Order� # Amoun� $ � Date:�d`�`�-� y
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Paid BY; i �,�---1'`��:-•� Received By: � �'G-
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Account #: �_�.� Invoice #:
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