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Permiccee's^����5.� � ���� �,�.;,;DA��E COUNTY HEALTH DEPARTMENT
Name: Environmental Health Section PROPERTY INFORMATION
��� ���-., ��� � P.O. Box 848
Directions to property: Mocksviile,NC 27028 Subdivision Name:
�'�rj;,,,� C!_._� �,,,,� �<���v i�y� "� L}L,,.� Phone#:336-751-8760
� Section: Lot:
; .., � AUTHORIZATION FOR
t��-- .� � ��='�'�'�'�� Ct�,� �:,i� �'-Tn.�.C, �..n� WASTEWATER Tax Office PIN:# -
'� ,�� "7 SYSTF.M CONSTRUCTION -
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AiJTHORIZATION NO: 1� Road Name: " Z�p:�-7`�-�'��
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pecmits.This Fom�/Authorization Number should be presented to the Davie Count}t Building Inspections
Office when applying for Bu' 'n�Permits.
(ln compliance wich Article 11 of G.S.Chapte ;130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
; �
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/v '�•, �' �t �`�—r" �� �� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONIv� TAL HE'A H ECI LIS rDAT ISS ED
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RESIDENTIAL SPECIFICATION:BUILDING TYPE �",�`#BEllROOMS `-� #BATHS Z #OCCUPANTS � GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE�'��WATER SUPPLY ���"�" DESIGN WASTEWATER FLOW(GPD) +� NEW SITE REPAIR SITE �
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `"��,' ROCK DEPTH ��" LINEAR Ff.��7
As �tnte� in ?.5A f��AC 1£tA.19C�(�D
oTxER � �.7i4�'jQ1�t�T1� �'� � �ccepted S�!st�.rr,s n�ay a�so �e us�r9
REQUIRED SITE MOD[FICATIONS/CONDITIONS: '^"`��h'L�— �� �TC�"? ��%'� � �p�"' ��L;-�--
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IMPROVEMENT PE MIT LAYOUT
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FlSR FINAL INSPECTION OF THIS SYST'EM PLEASE CALL BETV�EEN 8:30-9:3 'A M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
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OPERATION PERMIT ' /�
a`, � \ I� �INSTAL e� l.'`O�s � �
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AUTHORIZATION NO.�OPERATION PERMIT BY: DATE.
t�THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE AT 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 TIME.
�D�2«�,�� ��� ��3q� ..�"tir�.�`���/�
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�� � � � VIE COUNTY HEALTH DEPARTMENT
� � �� � Environmental Health Section
� ^ � 2��� '� PO Box 848/�10 Hospital Street
� � � Mocksville,NC 27028
� ���tM Phone: (336)751-8760
'` _„�-,� .s,,��c�Y��"jH . • . •
��-� '��� ":.O`�=�5 TE WASTEWATER CERTIFICATION FOR DWELLING
. ck One) REPLACEMENT o . REMODELING o RECONNECTION o
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Name: ���IE'��"��e/lPu� ����� Phone Number:�����''���� (Home)
Mailing Address: ��8 �SfC�-t/"�/" �R/92 � (Work)
/�G�llGt/lC�j /t�� .Z�(1U.6
Detailed Directions To Site:_ �0� .sl�l� ,��0/�fD ./�/G(Gi'�'l!/�7 �-Oi'1f0 .��'���'�
���r�a _S�r�- 1a.�� �Gsr �r��n�r>`� �f e�r�° v� ���
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Property Address: v?et� �S�li/`r ,�G�L2.�,,g-Gll1�CLLlIC�i � �70G� l�rf'��'S(�''(���
Please Fill In The Following Information About The Existing Dwelling: ,
Name System Installed Under:����"��� Type Of Dwelling:S�/fGLFk1/�4L' Ll�h'���`"
Date System Installed(Month/Day/Year): �D�Z��q6 Number Of Bedrooms: � Number Of People:�_
Is The Dwelling Currently Vacant? Yes� No 0 If Yes,For How Long? �d ��°l�/'.S
Any Known Problems?Yes❑ No C� If Yes,Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling:p�l�l"l�/��2 Number Of Bedrooms: Number Of People: �
/
Requested By: �,��� Date Requested: !'���'Q.�
( ignature)
_ For Environmental Health Office Use Only
Approved 0 Disapproved ❑ �
Comments: 1�`�Y��'�,f'�i� �t�'t 1 I SSc�t� Z�Z���1 Zo u����
�ys.,T��._. .
y M�^ �
Environmental Health S ecialist � Date '@�
P -��
�-`'
1 �
'"�The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a
guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash❑ Check❑ Money Order 0 # Amounr $ ��� Date:
Paid By: Received By:
Account #: ��91r1� Invoice #: