378 Pineville RdPemtiaee's /j /2DAVIE COUNTY HEALTH DEPARTMENT
Na", �%�% / ].r .� �./ �. `1f< z,11 Environmental Health Section PROPERTY INFORMATION
.. O �r P.O. BOX 848
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Directions to propeity: . � Mocksvillc. NC 27028 Subdivision Name:
Flt'✓ Phone #:336-751-8760
tUTH%FOR
WASTEWATER
Tax OI'icc PIN :#
SISfFNI CONSTRUCTION
AUTHORIZATION NO: 2060
A Road Name:
Loc
"`NOTE" This Authorization fur Wasted'uter S)mem Construction MUST BE ISSUED by the Davin County Environmental Health Section prior
to issuance of an)Building PcnunF, This Fom✓AWhuritation Numher should he prenentcd to the Davie Counq' Building Inspections
Office when applying for BuildingPennitn.
(In compliance with Aniele I I of G.S. Chapter 130A. Wastewater Systems. Section.191M) Sewage Treanntenl and DisrxAal Systems)
..., .._........................ ..... ............. _.........
IS VALID FOR A PERIOD OF FIVE YEARS.
DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE A'T #BEDROOMS.4 a BATHS j P OCCUPANTS GARBAGE DISPOSAL: Ycsor No
COMMERCIAL SPECIFICATION: FACILITYTYPE #PEOPLE_ #PEOPI.E6HIFT_ #SEATS_ INDUSTRIAL WASTE: Y#s .,No
'LOTSIZE TYPEWATERSUPPLY( /I DESIGN`A'ASTEWATERFl.OWIGPDI[-,�J//) NEWSITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SRE _GAL. PUMPTANK GAL. TRENCH WIDTHRrK;KDEPTH 1/LINEAR FT.c�—I!
REQUIRED SITE
IMPROVEMENT PERMIT LAYOUT
Rw �rmiIkI, #rf� -u x
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^CONTACT A REPRESENTATIVE OFTHE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR L W - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM
AUTHORIZATION NO. i ` OPERATION PERMIT BY: A24� DATE: Z-1�113
..THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
W 1H ARTICLE II OF G.S. CHAPTER 130A. SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BE TAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OFTIME.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME n e C�-a PHONE NUMBER
ADDRESS �- —?, ' =� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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