815 Redland Rd �,� :�.:�y , s.�.,.: ' f ;.. .' ..;: .:'�.•:'a r._.:. ..�:..-F �}:�;-,- ,....:,;, -. , -,r;�t ':.., �,_ , :- .-'a�. �::.- � .:.-:._. , . . . ,. _. � .�.
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Permittee s �. ,� � D VIE COUNTY HEALTH DEPARTMENT.
,Name.- - -- ' �- �-D`��� Environmental Health Section �O ERTY�F�RMA��TI0,�1 �
��;...-,� P.O.Box 848 � y �S�
� , Directions to property: I S C� �L� �``L'���•�^���ksville.NC 27028 Subdivision Name:
(�N �'t� �v.�� �' f� Phone#:336-751-8760
) `'" J �+,=�i, ` �,�.;-f�`.,�,^) Section: Lot:
AUTHORIZATION FOR
�f1 �'� WASTEWATER Tax Office PIN:# _
n SYSTF,M CONSTRUCTION
AUTHORIZATIONNO: � � �"� A Road Name•.t��``� ���•'���1^:fi) �t'�' r'
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**NOTE**This Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pemuts.This Forni/Autliorization Numt�er should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
__.._ ;-�``� 1 . .
_s � ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t+�' . ' r^�• I/ C)" IS VALID FOR A PERIOD OF FIVE YEARS.
''ENVIRO E �Ak�,_EACTH SF�EC(ALI�`T DAT ISSUED
�
• RESIDENTIAL SPECIFICATION:BUILDING TYPE_���#BEllROOMS�#BATHS �1 #OCCUPANTS�_GARBAGE DISPOSAL:.Yes,or No
COMMERCIAL SPECIFICATION: FACILI7'Y TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY �"���-- bESIGN WASTEWATER FLOW(GPD)�G--�— NEW SITE � REPAIR SITE '"�
. �� �� ,
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH '� LINEAR FT.�
OTHER _ . .
� •
REQUIREDSITEMODIFICATIONS/CONDITIONS:__ ��� � i,�F I.�l�l.- �
IMPROVEMENT PERMIT LAYOUT FCzA^M� • I�
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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.7'ELEPHONE#IS (336)751-8760.
OPERATION PERMIT �'_C�� I� " � I •1 '��� `
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. ��OPERATION PERMIT BY: � DATE: �� C.LJ
•'THE ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE THAT THE DESCRIBED AB VE HA BEEN INSTALLED IN COMPLIANCE
WTTH ART'ICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYS " UT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATTSFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02ro2(Reviu� .
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� , � DAVIE COUNTY HEALTH DEPARTAAENT
� "" IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPL�TIO�
*NOTE:Issued in Compliance With Articie I I of G.S.Chapter 130a
Sanitary Sewage S stems Q Permit Number
Name ' 7� ` �1 �l��A� � Date ���—y�_ N� 7 l�- C��
Locatio — Azl ��/'�,,�?� ,�����iii� /.��i�� ;
Subdivision Name Lot Na Sec. or Block Na
Lot Size House � Mobile Home _� Business Industry '
�
i
No. Bedrooms � .No. Baths �- No. in Family _ PublicAssembly Other i
Garbage Disposal YES ❑ NO p� Specifications for System: j
Auto Dish Washer YES p NO B' �/ � �
Auto Wash Ma:hine YES ❑ NO p� �Q�/�3 ,�p��/' �;�a�/ �
Type Water Supply ����/_ __— �
. •This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change. j
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Improvements permit by __�1�
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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., I
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completlon.Telephone Number:704-634-5985. )
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Final Installation Diagram: System Installed by L I
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Certificate of Completion Date
'The signing of this certificate shall indica�e that the system described above has been installed in compliance with �
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function �
satisiactorily for any given period of time.
2,'Dca t�'�1
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION l�,
• , APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) v /
1 �p. � �
NAME `�� � PHONE NUMBER f � �`���
� ADDRESS v�� `�� "`' '`���"� SUBDIVISION NAME �
/ �
LOT# �
DIRECTIONS TO SITE
7
. �
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DATE SYSTEM INSTALLED '"�S 7 � NAME SYSTEM INSTALLED UNDER �4�^-L
TYPE FACILITY b�� NUMBER BEDROOMS � NUMBER PEOPLE SERVED
:3!
r TYPE WATER SUPPLY 1� SPECIFY PROBLEM OCCURRING _ ��J�Y�G�^��
' ..� �
DATE REG�UESTED � � INFORMATION TAKEN BY �
This is to certify that the information provided is corcect to Me best o}my knowledge,and that I undarstand I am nsponaibie tor sll chargea incurred irom thie applicatlon. �
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93
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