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' `"Permittee's /� ,/ ��/--- DAVIE COUNTY HEALTH DEPARTMENT
Name: � j�t/�/f /!d f�/`11� � ` Environmental Health Section PROPERTY INFORMATION
�- f''�' : P.O. Box 848' ` G'rL�y�e/y
Directions to property:j�� . 5,������ hQocksville,NC 27028 ' Subdivision Name: '
./ � Phone#'.336-751-8760
�3.�, f ,i'`�ii=�G�-f if;f/l �✓-� Section: Lof: .,
A THORIZATION.FOR
��/����rr ��� �i��.,T j �j��;�1�f� WASTEWATER Tax Office PIN:# - -
.-�^�� S STF.M CONSTRUCTION
��
ALJTHORIZATION NO: �' A � ' _ Road Name: Zip:
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior '
to issuance of any Building Perntits.This Fomi/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(in corpp�ance with Article 11 of G.S.Chapter 130A.Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
J r
',/ �,� �- �1,.�'� �✓ ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�"" ��"�: �~���7 �� r �� IS VALID FOR A PERIOD OF FIVE YEARS.
..—�
E VIRONMENTAL HEALTH SPECIALIST DATE I SUED
RESIDENCIAL SPECIFICATION:BUILDING TYPE /�7 #BEllROOMS � #BATHS�#OCCUPANTS�_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIF[CATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No .
LOT SIZE TYPE WATER SUPPLY `� " DESIGN WASTEWATER FLOW(GPD) !�V NEW SITE REPAIR SITE �
i /. '�J�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH��' ROCK DEPTH� LINEAR Ff.�.:/� ,
, � OTHER ';
REQUIRED SITE MODIFlCATIONS/CONDITIONS: '
;
IMPROVEMENT PERMIT LAYOUT , ` •
�'Q/YJf d'L y Q`7" • ' �.:.'._.,. '
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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.TELEPHONE#IS(336)75 8760.
OPERATION PERMIT , /Q/�
SYSTEM INSTALLED BY: �t �
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AUTHORIZATION N . 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.CHAPTER 130A,SECTION.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 TIIvIE.
DCHD O1A2(Revise� �'�`--�!1 � �pJ ��
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �-
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) J D ��'`� -��n in�
NAME �'�- J T�-��/e-o c.J PHONE NUMBER �Q �-7?a- �
ADDRESS 1 � Y �a- �� � ��� -
�� C /�v 1 n� SUBDIVISION NAME '�' '
. �
In'1 � `k.S J� t l z LOT #
DIRECTIONS TO SITE l �" � T�.�-- � �'� �-'�-c.� G�C.-.h.--L o� �.�-,s�- �
w �
�.�. o �- ��a 4 � -- �v�.s�. b�.�i� �'.-a �, ��c..�. �a..� (���
DATE SYSTEM INSTALLED � s NAME SYSTEM INSTALLED UNDER �w4'�. T'��1 t,�e�.J
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY Ci'�"'�! SPECIFY PROBLEM OCCURRING .X�/�/C � t n-�"�J
wt'>— � `'--«- O ,�e..���
DATE REQUESTED �/ �z-� � � INFORMATION TAKEN BY � �.
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This is to certify that the intormation provided is conact to the best of my knowledgs,and that I understand 1 am nsponsible tor all eharpes ineunsd from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Hev.,/93
. +ep 08 03 02:54p davie county envhealth
�' 336 751 8786
y- `'. - ,� p.2
APPUCATUIN FOR SfiE EVALUA7I�V/11tPR0VEMEM PEM1iT b ATC
Davie County Heaith Depa►tment
Emironmenta/HesaltJi Seab�on
p.o. Soz 848/710 8ospital Sbreet
Hocksville, NC 57018
(736)751-8760
r�e�ppRTJtPlP**e TfIIS APPliIGTION CEAaVOT 98 PROCS33SD IINL833 N.L T� REQIIIRSD
INFQRfATION IS P&OVIDSD. &efar to the IN8oR1�B►TION atlLLETIA for inatructiona. //
�Nama [o be Hill�d��. • /v �i� Coauct Person v��7� ���/Jl�� ( ]���� ���'� '�Z l R
✓Mailia9 Addreee���f' J�v'"' T'7�'��/O�U ``� `
Home Phone //''��'' /��
v C1Cy/Stat�/ZIP , Z BWSnaYs PLoae - '�����j�f��"I `
v '
a� ]. ftaaN on ➢ornit/71TC i! D�Lt�r�at thea w� - �K�
� Mailiag 7lddreai C�ty/State/Zip
!/1. 7lpplicatioa 8or� O Sitw T.valn3tioa �Img=ovem�nt Pezmit/AZC O Soth
� '
�'�. eyu..co s•r.iea,�Iionea ❑ MoDiln Hcma ❑ Buainese ❑ indnetry O other
� 4�pe ry�tea r�qu�st�d:� Coc»ntlonal ❑ aoAvantlon�l modiiiad 0 inna�etivs
r
r/6. I! AaYidwcax �IIeople • Bedrooms �_ / Bathz'ooms Z
!i Oni�Druh�r QOubaqe Di�pnoal �asbiay MaeIIiw �6a�a►�ae/alimninp �8a�awnt/1ao Plimbing
7. 2!8mia�s//Inductr7/OtheYi �elStY tppe �P�oDl� ! 81nka
i Caorodee t 3bowsa f usinal� f Natez(bol�ra
IF FOODSSAVIC&s * Seata 8stimatefl Water IIasge (fl�loai p�r aay)
�/! t. iqya oi xatar �upplp� 1,� Covaty/City ❑ Nell ❑ Co�unity
l�
✓ s. no rou aocsasa•u,ansctone�r e:paosion:oi the[acllity thls rystem is Intcnded ta ccrn?0 Yes �No
lf yes,what type?
�*'IMPOR MPLETETHE REQUIRED PROP&RTY LNFORMATION REQUESTED
BEI,OW'. er a Pi.AT or SITB PL USTBESUBMl7TED b the ctiept wit6 TH1S APPLICATION.
v Property Dimenslons:�-� t'1 l� WRITE DIRECI'IOIvS(from Moclwine)to PROrERTY:
Tu0[tieePIN: #s���O�J� D 7� v' � s��IC/V5'� /V 6 �
„- P��n A�: �N.� �o S�n,�d C G� C��f� C�i vRc.�. o�
�ritipM��Xsv�tl�-z�oLg' �` oY
�.,jLlu.aS�a provide Information,as follows: O � /�
Cr Name• /V_� . 111l4/e �1��
t.�'
Section: Biock: Loi: pate home cornera ilagged:
TWs ia w arHty that We Intwmah��n pr»vlded is correct to fhe but of my knowle�a [nnderstand thxt any permit(s)
issued heresfter pre subj ect to suspenston or revocaHou,if the dte pl'm or inteuded ase ehange,or if t4e iatormatioo
sabmitted ia this applieatlon!s[als faed or changed. I,slso,w+darstand rhat I m:respoasibkfor aU charges Lresned jrom
this applicmion. I,hereby,�lve tonseat to lhe AutLorized Represenlative of t6e Davic Connty Health De ar ut
to entec opon above de.ur[bed property located in Davie Connty and o�rned by��l'�� �' �1 1'c n t�
to condad aa testing procedura a5 neaisary to determine the site suitability.
✓i3ATE � f Z d �SIGNATURE • �
TIDS AREA MAY BE USED FOk DRAWIlYG YOUR SI7'E PLAN(Indade all o[the owing: Ezisting and proposed
ProP�Y llnea and dimenilons,struettirts, aetbacln, and aepQc loca�n�j.
Z � Sitc Revisit Charge
s�j°��TA" `��'._7
Date(s):
�
Clieat No�eation Datr.
�e�is� EHs:
Sign Eiveo h) d Account Na
Itevised DCSD(OS�03 Iavoice No.
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