268 Rock House Rd . . ,. rT= : : :::.� :
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..Permittee's .��., ; ( DAVIE COUNTY�HEALTH DEPARTMENT = �__; -�-•�-.ti
Name: '��' � -�✓ZU Environmental Health Section � PROPERTY INFO�t AT�
�y
� .. " •• `�._,_-� ('� P.O.Box 848 � � ,' s � .
'�','D'uections to propecty: ���= �� ��il��.... Mocksville,NC 27028 Subdivision Name:
!:� , ) ' ( � , Phone#:336-751-8760
��-M' � . r V K:r.� r'�r� ,E - Section' Lof:
� AUTHORIZATION FOR
�['��:�;� . WASTEWATER Tax Of�ce PIN:# -
SYSTF,M CONSTRUCTION �
AUTHORIZATION NO: � ` �� A . Road Name: �� < "fi.��.� . � t,-'�i`d�%`�•�?�
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Pecmits:This Fo►m/Authorization Number should be presented to the Davie Counry Building Inspections
Office when applying for Building Permits.
(ln complian�with Article 11 f G.S.Chapter 130A,Wastewater Systems,�Section.1900 Sewage Treatment and Disposal Systems) :
_ ,
�;� J� � ``� � r� .,x ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION
. ;�,�r/'""�. J 1"'�\. '^ � C�V IS VALID FOR A PERIOD OF FNE YEARS:
`'�MENT�1 LTH SPE�IALIST DAT ISSU D �
� _ �' �. . � . . .: .
RFSIDENTIAL SPECIFICATION:BUILDING TYPE � #BEllROOMS ? #BATHS_�#OCCUPANTS..3 GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFf #SEATS INDUSTRIAL WASTE:Yes or No
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LOT SIZE Z'f��E WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD)__�4�NEW SITE REPAIR SITE ✓
�/ ' �
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH�Z LINEAR Ff.�
OTHER � t� '_�1C/�IF�-1/'i�L� �X.�S __.
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REQUIRED SITE MODIFICATIONS/CONDITIONS: �-t�t%C �--t.� "t 1�v+�. (,N Q-L. . ��� � �/ ��f'1". ,PG�t�• (�►��
IMPROVEMENT PERMIT LAYOUT � -----^�R�`
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*•CONTACT A REPRESENTATIV�QF TH HEALT$DEPARTIvIEN7`FOR.�"INAL INSPECTION OF THIS SYSTEM
• BETWEEN 8:30-9:30 A.M.OR I:00-130 P.M.ON THE DAY OF INSTALLATION.TEL�'EPH(1�E#IS (336)751-8760.
OPERATION PERMIT ' ��� �� "
SYSTEM INSTALLED BY: �� r� <.�Z,�f ( 1 C� I�^�` Y
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AUTHORIZATION NO. ����A OPERATION PERMI'� . DA •
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•�TE�ISSUANCE OF THIS OPERATION PERMIT SHALL THAT THE SYSTEM DESCRIBED A E HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S.CHAP'TER 130A, N.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 07J02(Revised)
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� ' ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME I ���% c� TI�� ! PHON NUMBER 1`f� �t �1 �
�� ! ��
ADDRESS ��% SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE �
. Y` 7
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DATE SYSTEM INSTALLED � ' NAME SYSTEM IN ALLED UNDER i �t�I�J ��'l T� �
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TYPE FACILITY J� NUMBER BEDROOMS 2. I NUMBER PEOPLE SERVED 3
TYPE WATER SUPPLY Vv�� SPECIFY PROBLEM OCCURRING �/�s`rt��� �
I
DATE REQUESTED � � �� INFORMATION TAKEN BY �
' �
This ia to oertify that the intormation provided is corced to Me best oi my knowledge,and that I underatand I nm rasponsible for ali charpes incumed from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Fiev.t/93
- '�� • ' DAVIE COUNTY HEALTH DEPARTMENT �
. � ' (Septic Tank) •Improv.ements Permit and Certificate of Completion .
(Ground Absorption Se�rage Disposal ,System - G.S. Chapter 30- rti le 13C)
+ OWNE OR CONTRACTOR �' . � �
/I,�C�t-•�•d.�rl� � �-�•rc-��'..�'Z, DATE f PERMIT
� , ;;� ��� /� . f� � No 18 8 4
LOCATION ..:��' I G� 3'J ^^' '�c.r'� 'J • �{ .���r-cr�. /�it���- �' ...�., ,., . ,y. . .
1 S.R. N0.
SUBDIVISION NAME LOT N0. SECTION OR BLOCK N0.
HOUSE [�' MOBILE HOME BUSINESS ❑
=� House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS �"'� N0. B�ATHROOMS TWo Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO. .. L! Three Bedroom House 900 Gal. 900 Sq, Ft.
AUTO. DISHWASHER YES []� N0 . _0 Four Bedroom House - 1000 Gal. 1200 Sq. ..Ft.
AUTO. WASH. MACHINE YES (I] NO ❑
f'r,% �r
SITE SUITABLE YES ❑ -.NO : ❑ .' .. �`5;i;J.�- .. �� ��✓� �,,��w�C..,,
SIZE OF TA.NK gal: . _ . . _ _ :._ --- - . :,
. . .
. 4 ,� r �� ��
NITRIFICATION FIELD '. . �: := sq._ ft. �/'�� � „3 � . �
DEPTH OF STONE IN LINES: � _
:.��E1.- .
WATER SUPPLYi ' Individual � Public ❑
_�/; > -�-C/
IMPROVEMENTS PERMIT BY �Gx�+-. '.�C.-Lt�JC.z� � INSTALLED -BY .
CERTIFICATE OF COMPLETION By __ ._ . -. .. ._ _ _ __Date �
(8/16/73). � *Construction must comply_with all other applicable State and local regulations �
LOT AREA
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