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aTI�RIZATION No: 1807 DAVIE OUNTY HEALTH DEPARTMENT
�.
Environmental Health Section PROPERTY INFORMATION
Permttee'c / P.O. Boz 848 . .,
Name IE r!!I �✓ Mocksville,NC 27028 Subdivision Na me: : .
/l Phone# 336-751-8760
Directions to property: < jG.S Section: l Lot:
AUTHORIZATION FOR
WASTEWATER x Office PIN:# -
SYSTEM CONSTRUCTION :
RadName:h .,1i,,,o }—�=�L 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 Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen-nits.
(In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
a'y�t,.fii'..:7* fy * �.„,..�.....,-.1�"{ .y�r„ v,.,t i' '+t:h;"•� t"Y .1 L
��: ��. �= Pio �-9-�5•
DAVIEOUNTY HEALTH DEPARTMENT<
.47
"IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Perm els
7 , -
' Name: ��' 1r� � t_ ,� �:7"" � Subdivision Name: � !�' Y� �'i'►l�.
Directions to property: if <<'' Section: Lot: 3m
IMPROVEMENT
PERMIT Office PIN:#k
;�ax _.
lad Name:.f- = -�i'.... .. ^' 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
constructiorthnstallation 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)
yr ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE:
� a PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER,
ENVIRONMENTAL HEAL 'SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE ,H #BEDROOMS 3�#BATHS- #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW(GPD) �b l/ NEW SITE `'REPAIR SITE
SYSTEM SPECIFICATIONS:-TANK SIZE /,? d GAL: PUMP TANK GAL. TRENCH WIDTH 'ROCK DEPTH l LINEAR FT.�D
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
U
**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 �D /, `
X
_&STEM INSTALLED BY: 1/li
AUTHORIZATION NO. �D OPERATION PERMIT BY: DATE: `
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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)
APPLICATION FOR SITE EVALVATION/IMPROVEMENT PERMIT do ATC
Davie County Health Department
Environmenta/Hea/th S&WOH
Y P.O. Box 848/210 Hospital Street NOV z 4 �nntt��pp
Mockaville, NC 27028 IJV
(336)751-8760
ENVIRONMENTAL HEALTH
***IMPORTANT*** THIS APPLICATION CANNOT IM PROCESSED UNLESS ALL
INFORMATION IS PROVIDED. Refer to the
�INI MATION BULLETIN for instructions.
1. Name to be Billed �7 Contact Parson Ce -5�6 : /
Mailing Address e'4" '44)-off Some Phone
City/state/ZIP A/dC k2//'J/� Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/state/Lip
3. Application For: U Site Evaluation d1uprovement Permit/ATC Aftoth
4. system to service: ITHouse 0 Mobile Home 0 Business 0 Industry 0 other
s. if Residence: # People # Bedrooms # Bathrooms �.
9'Dishwasher 11 Garbage Disposal gr ashiag Machine 0 Basement/Plunbing 0 Basement/No Plumbing
G. If Business/Industry/Other: Specify type # People # sinks
# Commodes # showers # Urinals # Nater Coolers
IF FOODSERVICE: d Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City 0 Well 0 Community
8. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes 010
If yes,what type'
***1MPORTANP**CLIENTS AIUST0011[PLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Eilber a PLAT or SITE PLAN rMUST BESUBMITTED by the dlent with THIS APPLICATION.
Property Dimensions: �Ull i� r� 7Q VIRITE DIRE�CXION-S((from Moclavllle)to PROPERTY:
Tai Oifice PIN: # r�a — 6��_ b��i��t��� O /Y /U /1/'1"eta /`(4
Property Address: Road Name 16h e Glc IN 1-91 j
City/Zip
If in a Subdivision provide information,as follows:
Name: ohle /D A C-c- S'
Section: Block: Lot: 3.� Date Property Flagged: `c�
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
Issued hereafter are subject to suspension or revocation,If the site plans or intended use change,or If the Information
submitted in this application is falsified or changed I,also,understand that I am responsible for all charges lncuffedfrom
this appl3catiorr. I,hereby,give consent to the Authorized Representative of the DaviIFounty, ealth Department
to enter upon above described property located In Davie County and owned b. �--
to conduct all testing procedures as necessary to determine the site suits lity.
DATE �/ — ��— SIGNATURE t
THIS AREA MAY BE USED FOR DRAWING YOUR SITE P:] (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Account Na AAl
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