123 Sain Rd _ - _ . � . . . ,--._ ____ _ ._.....-
-Perm;cee's�� L /� DAVIF.�COUNTY HEALTH DEPARTMENT �. �
�vName: � 7r'i•�.�,�.:.- /�'�! ON F:nvironmental Heal�h�Sec[ion PROPERTY INFORMATION
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Directionstopropeny��1 —�1`,.:. .l-N A1ucksville. NC27038 SubdivisionNiune:
,�� � .� / Phnnen: 336-75P8760
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AUTHONI%ATION�FOK
N'ASTERI�TF.R Tax-0ltice PIN:q
q SYSTF,M CONSTRUCTION
AUTHORIZATIONNO: 25787 p RoaJ.Nume: 4„✓ /Qd, ,7�r;
"NOTE*'This Awhoma�ion for Wasmu;ucrSwtem Gun�wc�ion MUST BE ISSUED bv Ihe D:rvie CimnieEnvironmem.il Hr�hh Seciion priur
�o issuanee of any BuilJin�Pemiitc'(liis{nmdAuthorizmion Numlx:r shnulA hc prcsen�ed iu�he Davic Cnunry'Building Inspeciiiins
Offce whcn upplying for�uilding Pcmiiu.
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RESIDENTIALSPECIFICATION:BUILDINGTVPE# peEUROOMS�aBATNS�pOCNPANTS '��GARBAGEUISPOSAL:YesorNo
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COMMERCIALSPECIFICATION, FACILITYTYPE aPEOPLE_ pPFOPLESHIFT_ �p5EAT5_ INDUSTRIALWASTE:YcsarNo
LOTSIZE TYPEWATERSUPPLY C O OESIGNWASTEWATERFl.OW(GPpIVI�_� NEWSITE REPAIRSITE Y
SYSTEMSPEQFlCATIONS: TANK'SIZE GAL ��PUMPTANK�GAL. TRENCHWIDTH �� ROCKDEPI'H�ULINEARFfS�/f!J
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OPERATION�PERMIT
SYSTEM INSTAf:LE BY
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AUTHORIZATIONN . OPERqT10NPERMITBY:
'•TNE ISSUANCE OF THIS OPERnT10N PERMIT�SHALLI,YDICATE THATTNE�SYSTEM DESCRIBED qBOVE�HAS BEEN INSTALLED IN COMPLIANCE
WITN ARTICI;E I I'OF QS.CHAP'fER 130A,SECTION.I900"SEWAGE 7REATMENT qND DISPOSAL SYS7EM5",BUT$HALL IN NO W AY BE TAKEN AS A
OUARANTEE TNAT THE$YSTEM WILL FUNCf10N SATISPACfORILY FOR ANY GIVEN PERIOD OF TIME.
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� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �
� � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) "�
NAME S���.� �^c C e y PHONE NUMBER�� �� Z Z
ADDRESS �� 3 Q � �' /� " SUBDIVISION NAME
//I/�-�C `CS.J< ���' LOT #
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DIRECTIONS TO SITE I s � d � �a-t r' — l S f
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DATE SYSTEM INSTALLED �o S ' NAME SYSTEM INSTALLED UNDER '
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY �� ����SPECIFY PROBLEM OCCURRING �`�� �'�--� �'
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DATE REQUESTED ��� � INFORMATION TAKEN BY
This is to wrtify that th�information provided is eomct to ths best of my knowledps,and that I understand I �nsponaibls}or di eharges incurted from this application. �
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SIGNATURE OF OWNER OR AUTHORIZED AGENT
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