1109 Sheffield Rd �. :.f1,�r�.�� .-•.:'-. i-� . .s.:��'a .,y-i..rip'-r.,i�-ir- �-i�-ins'°-�1+ � -.��s-1:'`"r x-ar �; f��. _ . . ..J.��.�h}5 �„ K`s t�' ir�r u•,'��.�a:f'�e'�'�.,, � . +,,>�'��bs�q.:.:y'`4
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'-AUTHORIZAT1oN No _ � � �(��llAVIE COUNTY HEALTH DEPARTMENT 4 "� -3 ��(I Z
`Env�ronmenfal Health Section ` PROPERTY INFORMA ION
Permittee'. - P.O..Box S48 '
Name:��Q�`,f� ' ,���'��C�,, ;� Mocksville,NC 27028 - Subdivision Name:
� / / �^,�'!" f P6one# 3�36-751-8760
- Directions to property: //�,���,�'�'�_7. � 1�,�'``�" ' Section: Lot: :
• � AUTHORIZATTON FOR
�,���� J ���� WASTEWATER Tax Office PIN:# - -'
SYSTF,M CONSTRUCTION
. - , . ; ' , " ' Road Name: ' ` Zip
**NOTE**This Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Section prior
'to issuance of any Building-Pernuts.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits: � '
(ln compli ce wi icle l l of G.S.Chapter 130A,Wastewafer$ystems,Section.1900 Sewage Treatment and Disposal Sysfems)
,, - :
�'' ,t !! �,� ' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
' ,. r,`j�.� •� � i"� �;,- • ;�' , IS VALm FOR A PERIOD OF FIVE YEARS.
EN ONMENT L HEALTH SPECIALIST.- , DATE ISSUED ,
FY �� 4� �.�i f .. �` _ ._ .i �" . J.<�ai-: .'�=..-.. - . y " ._., ". - vFi .S.�l � - i . ... .)'�. w . ' ���R:4 k
k ' '. . ��'� t- � i ��'''�t-'.'�. ' <' : p
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�;r€�` "'� .�- --�- ',:- tF;����DAVIE COUNTY H ALTH DEPARTMENT . �� -� C/ �J� .
, � � �sr�
��, �, ��-.�,,-.s:� IMPROVEMENT A OPERATION PERMITS PROPERTY INFORMA ION
' Permrtfee�� ' ^7 ;
j • a �_: �.�
- 'Name: �� �0 �/)� � ;��� ��°�°:'a==���1 :;, Subdivision Name:
�- - - _. �-
,:, .^r . . , .
- , .. . ..
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Directions to property: �i�1�1' -.3..';f:�'�'�} �f+�'�, J �P .�_�Sect�on` " - - -- - - Lot:
� Il14PROVEMENT : .
' ` `�.����'SL - ��� �f�/�� PERMTI' Tax Office PIN:# - - �
_ Road Name: _ Zip:
y **NOTE**This Improvement Pemut DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system.An
ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON must be obtained from this Department prior to the
' " construction/installation of a system or the issuance of a building pernut. -
(In compliance with Article 11 of G.S.Chapter 130A,.Wastewater Systems,Section.1900 Sew�Treatmentand Disposal Systems)
: , ;
i �. :✓` ' �;�+� y �'' i�,: **sNOTTCEss*TEIIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�r••�'r.,: /'. .j';r�f'•..�/ t� �: : ..• r . PLANS OR+THE IlVT�NDED USE CHANGE.YOUR WASTEWATER .
•�.;:ENYIRONMENTAL HEALTH SPECIALIST DATE ISSUED • . . SYSTEM CbNTRACTOR MUST SEE TIII.S PERMIT BEFORE
. nvsTa�.Lnvc�sYs�. ; - � :,: :
., , . . . , . :.. . . � � . ' . . ,. . .,
_ _ . �:
RFSIDENfIAL SPECIFICATION:BUII.DING T'YPE,�/� #BEDROOMS�#BATHS � #OCCUPANTS GARBAGE DISPOSAL:Yes or No
� ,COMMERCIAL SPECIFICAT'ION:,FACII.ITY TYPE #PEOPLE #PEOPLFISHIFT #SEATS INDUSTRIAL WAS1'E:Yes or No
. • . .,.,•..
' LOT SIZE� TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD): �f��� . ; � ; • ,
` —`�=�C� NEWSTI'EJ REPAIRSITE�_�.:_ .
�� �` � ��� :
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL:•-TRENCH WID ROCK DEPTH LINEAR FT
OTHER .
REQUIRED STTE MODIFICATIONS/CONDTTIONS:
IIvIPROVEMENTPERMITLAYOUT�APPROVED EFFLUENT �ILTER� *RISERtS) IF 6�� �EL01J FINISHEA GRADE�
, , �
. . S . . . . . . . ,
. . _ . ' . . � . . . . �/�. � . . . . . .. . . . . _ ..
� � .. . ' � . . . � . ' � . . - -� . � 4 Y�CK/ . . . � � _� '�
. . . . • . � � �� � , _ I" . . .
' �j�r�{C-�- � ��
�
'*CONTACf A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM .
BETWEEN 830-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLAT'ION.TELEPHONE#IS(�4���'��S x
(33b)751—Q760 ,
OPERATION PERMTf f w� J � �'
SYSTEM INSTALLED BY: ��� � , 2't�
: r
_ � , . �1� �
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� / !
_ �
AUTHORIZATION NO�OPERATION PERMTT BY: �/ DATE: G ,
••Tf�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE :
. WITH ARTICLE ll OF G.S.CHAPTER 130A,SECI'ION:1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII,L FUNCTION SATISFACTORILY FOR ANY GNEN PERIOD OF TIME.
DCHD OSN6(Revised)
��:
.
_.
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
'� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �„�
. �� , ti •
NAME e-� � � C � PHONE NUMBER �
- �
� ADDRESS I� � �l �� ��-�� 1�d . SUBDIVISION NAME �(�
� D G�S t/i��-2. J��— LOT# �
/
DIRECTIONS TO SITE 7
� �
. �
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILIN NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �
�
(^�,
Ov �
DATE REQUESTED � L� INFORMATION TAKEN BY
This is to certitify that fhe intormation provided is corred to the bast of my knowledge,and that I underetand I am responaible for all charpes incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.t/93