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1226 Rainbow Rd
. ,i . . :� � � _ . . - . .. .r . . . �- � �, ` �.�:,�`�� l..�'�. 'Permittee's'.., ,,,� : DAVIE COUNTY HEALTH.DEPARTMENT �, � . ,.,,,.� Name: -',��"�'-�.1+�1���'' ��'�-��. Environmental Health Section PROPERTY INFORMATION �''-� V __ -� . r. ._,_ . ..- ._: --�,� P.O:Box 84$ .`....-;-- 1 �.`La �.: �=�'r�,+.�5� � —D�-�-.,...�.... � Directions to property: Mocksvilie,NC 27028 Subdivision Name: ' " �^-� Phone#:336-751-8760 � �jG�.:.,, +..L'...) a-� «�,r.1�.=+� Section: Lot: (� � AUTHORIZATION FOR �/p t,,, t o•-� `�J ` . ' .WASTEWATER Tax Office PIN:# SYSTF.M CONSTRUCTION - - ` AUTHORIZATION NO: ����E � A Road Name: �"�� ��a►�p�ip t:.���� **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Counry Environmental Health Section prior to issuance of any Building Permits.This Fom�/Authorization Number should be presented to the Davie Counry Building Inspections Office when applying for Building Permits. (ln complianc�ich�Article�1 of C'• . �a er 130A,Wastewater Systems,Section,1900 Sewage Treatment and Disposal Systems) / ���: t-j. ,..-� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION t� � �� IS VALID FOR A PERIOD OF FIVE YEARS. ENV[RO .' TAL� H pEC ALiST DA ISSUED r 7� RESIDENTIAL SPECIFICATION:BUILDING TYPE µu��=-#BEDROOMS +� #BATNS .� #OCCUPANTS'�+ GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFISHIFI' #SEATS INDUSTRIAL WASTE:Yes or No . LOT SIZE (','`—�-"TYPE WATER SUPPLY ��"�" DES[GN WASTEWATER FLOW(GPD) � NEW SITE REPAIR SITE � SYSTEM SPECIFICATIONS: TANK SIZE '�p� GAL. PUMP TANK GAL. TRENCH WIDTH �L', ROCK DEPTH �z'•/ LINEAR Ff. `'W� oT[�[ER Z �tG�J TW� '�rt.• c a REQUIRED SITE MODIFICA ON DITIONS: `����-�- U'� ���`�� IMPROVEMENT PERMIT L OU �Op � ,ao , _ �o�� �q� , . � _ 3�•. �^j2 ,' . N f—\ �� , �+ N�us� �, � �'ti t S-r�..� v �. - _�Yst� , .. � , . �� t -�.Jca'r K . . . . . . ' .. ,. . . . . . . . � . . , t� r:� w,j� . .� . , � . - 1 (,Z1�/� . '*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM � BETWEEN 8:30-9:30 A.M.OR]:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT � /-� �r�e SYSTEM INSTALLED BY: 'o �1'''1`�,L,.� ,� : � . 5 � � _ : G�'�`� e�� _ AUTHORIZATION NO.������OPERATION PERMIT BY: DATE: � � **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAP'fER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAYBE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 0?J02(Revised) � � � N�J _._. _ i , � J �/'� � ,v / --� :- , � : <. � ��� � � 9 p . ��_. � ��'� ���� . ' � . ,• A • ._ , � ' �� A R SITE EVALUATION/IhiPROVEMENT PERMIT&ATC�� �"��� '� � avie County HealEh Department Q - � 2�Q5 vironmenta/Hea/th Section 3�, a � Cd�'a' � y pQ� �yg .O. ox 848/210 Hospital Street ocksville, NC 27028 s-,��f� p��1FA� (336)751-8760 � (�./��S�""`'� -0 O�aME��� ***IM ORTANT ** APPLICATION CANNOT BE PROCESSED U2JLESS ALL THE REQUIRED INFO TIO PROVIDED. Refer to the INFORMATION BULLETIN for instructions. • 1. Name to ba Billed �C/GU�'/�U �� ��q-e j� Contact Pereon �Q!vJ � Mailing Addreas ��.,1�j �(/��1�/7R-L(.�� �C�i Home Phone '�] ( [}'�Z�_ City/State/ZIP /?Ql�/�y/�e�� �, r�-7����'�7�0 Buainesa Phone � 2. Name on Permit/ATC if Different than Above Mailing Addresa City/State/Zip 3. Application For: ❑ Site Evaluation ` �V�l Improvement Permit/ATC ❑ Both i � � 4. syatem to service: L�House 0 Mobile Home ❑ Business ❑ Industry ❑ Other 5. 1�pe ayatem requested: �Conventional ❑ coaventional modified ❑ innovative • 6. If Residence: � People Z # Bedrooms Z. # Bathrooms _� ❑Dishwasher ❑Qarbage Diaposal ,�Washing Machine ❑Hasement/Plumbing ❑Basement/No Plumbing 7. If euainesa/Induatry /Othar: verify type # People # Sinka # Commodes� # Showers # Urinals # FTater Coolers IF FOODSERVICE: # Seatu EBtimated Water Usage (gallons per day) 8. Typa of water supplys � County/City �Well � Community 9. no you anticipate additions or expansions of tl�c facility tl�is system is intendcd to scrvc? O Ycs �No If ycs,wl�at typc? ***IMPORTANT"'**CLIENTS AIUST COMPLETE TIiG RCQUIRCD PROP�RTY 1NFORMATION R�QUESTCD BELOW. Cithcr a PLAT or SITG PLAN 1�fUST I3E SUI3AlITfL•D Uy thc clicnt �vith TIIIS APPLiCAT10N. Propert Dimensions: /� �✓�—_� 1VRITE DIRECTIONS(from M villc)to PROPGRTY: x orr,��rlrr: # c��� ��-v `��- E a �,� Property Address: Road Namc � ti�' ��/✓ � /�'I � �-P� �D . �• � � � �� �t� City/Zip /����iZL1�CPi�/✓, �DoL ���-t�1— ' ICin a Subdivision providc information,as follotivs: �� /�CL�.�� /JG'�f2 Namc: ���r� .GL"�P� ,efG��.e�fi Section: Blocic: Lot: Datc l�omc corncrs fla gcd: �"�� . . Tl�is is to ccrti[y tl�at tlie information provided is corrcct to tlu best of my I:no�vledge. I undcrstand tl�at any permit(s) issucd liercaftcr are subjcct to suspension or revocation,if tlie site plans or intcndcd usc changc,or if the information submitted in tl�is application is falsified or cl�anged. 1,nlso,rniderstaur!tlrat I anr responsible jor all clrarges iircurred jroiu 11iis npplicatiar. I,hercUy,give consent to tl�e Autliorized Rcpresentativc of tl�c Davic County IIcaltl►Dcparhnent to entcr upon abovc dcscribed properly locatcd in Davic County and o�vncd by to conduct all teslii�g procedures as necessary to determine tl�e site suitability. DATC ��l� D� SIGNATUIt� t , � • ; TIiIS AItEA MAY BE US�D FOR DRAWING YOUR SIT�PLAN(Includc all of tl�c follo�ving: �xistiug and proposed property lines and dimensions, structures, setbacks, and septic locations). Silc Rcvisit Cl�argc ' ; Datc(s): �—.� Clicnt NotiGcation Datc: � �/� �HS: . r �- r Sign givcn C�����' Account No. �� � � ! `}!O ° Revised DCHD(OS/03 �� Invoicc No. � �� � .. .1 1 , w ,.. V �. .TT"�� �_, �y�F� 1 3. � � � �Y4"' "P` .�Y : -� �'^' i /' �+ . �v.. � e..t ^ � �..e,F158 � ''`�� � � yi �� ��,�t�� '.;a � � - .:� �-- ti 8 4t.^' p�.('�MAN L ��t', �' � �' ` i��"'. '�„�x,sr-w��^i ��' .. ,i F \ .- . :� � � y �-"� t �"' ?� ° :s . 3� . �� .��y�;. � � . c . ;;A .t �\ .,� � �gq. 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