613 Pine Ridge RdAUTHORIZATION NO: `j8 0A DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPER T RMATION"
Permittee's P.O. Box 848
Name: Lr, ��`�' I� ��` t' 1 Mocksville, NC 27028 Subdivision Name: —�
Directions to property:. 6,0 1s �4' �Y1^� Phone # 336-751-8760 Section: Lot:
AUTHORIZATION FOR
-14 WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
Road Name: tp:
**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 when applying for Building Permits.
(In compliance wo Article I 1 of ' S. Chester 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
'1-411
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
y P IS VALID FOR A PERIOD OF FIVE YEARS.
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ENV1R0NMFrjjAL HEALTH SPECIALr J DAkE ISSUED
t s a #DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY Jh FORMATION
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Permittee s
Name: ' 0 'i''.► 1
.Directions to property: t t: 1 I` '" L r
- IMPROVENT
( .1.•'1 i�_..;� -� i �� PERMIT i
• 1
Subdivision Name: \,. .! 1�11 ( / J
Section: Lot:
Tax Office PIN:# - -
Road Name: ';�c ` /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 I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
/ PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMEN'T`AL IIEALTH SPECIAL ST DA/I'E ISSUED
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPEWt # BEDROOMS # BATHS ( # OCCUPANTS 2 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPtECIFICATION: FACILITY TY�PE-,) # PEOPLE # PEOPLE/SHIFT {' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE+nLIA'� TYPE WATER SUPPLY `^ "^�7 DESIGN WASTEWATER FLOW (GPD)�
NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �L' ' ROCK DEPTH 12 ' LINEAR FT.•— DC:
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: �aLl v --� c-c� JTuU
IMPROVEMENT PERMIT LAYOUT
-APPROVED EFFLU24T FILTER* tRIS-r: IF 611 BELGA FINISHED GRADE*
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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 (7" {3.4p82S St
OPERATION PERMIT ( U n _
SYSTEM INSTALLED BY: �j (�-�1j/w
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AUTHORIZATION NO. T McQi V I\ OPERATION PERMIT BY• I DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT ��XED ABCE HA EN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEM UT 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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SEGTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) /
NAME ��✓ �'�-V / /�� '� rG� PHONE NUMBER
ADDRESS �r� �� �- /C.• SUBDIVISION NAME
h1 O %/V L LOT #
DIRECTIONS TO SITE 6 5 (� / /�.,.� 4 L e
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-
A:raY\ Ba,C
DATE SYSTEM INSTALLED �� fs NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED �—
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRINGQ-
t�c.,.—� e�..c e�.� Z - 3 rs� s 4- � --- f •s.J'. /u.��C' ,� , L � ----
DATE REQUESTED z a INFORMATION TAKEN BY.
This is to certify that the information provided is correct to the best of my
SIGNATURE OF OWNER OR AUTHORIZED AGE
Rev. 1193
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that I understand I am responsible for all charges incurred from this application.
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