442 Turkeyfoot RdF,. Yom.,• - .. > - -. .... �� ,
UTHORIZATION NO WDAVIE COUNTY HEALTH DEPARTMENT '� 3 0
NlJ4' Environmental Health Section PROPERTY INFORMATION
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~ [- \ P.O. Box 848
Name: ` VJ�;(3T�L ^ 1 Mocksville, NC 27028 Subdivision Name:
Phone # 336-751-8760
Directions toproperri.f(T��C' T�7 �� ��L�LL Section: Lot:
`r n AUTHORIZATION FOR
L) LE -- WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
a t.e t- -I VC V-,- F � I n
Road Name~ Y Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In complianc with. Article-'] I of G.S. Chapter OOA, Wastewater Systems, Section.. 1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r r''0IS VALID FOR A PERIOD OF FIVE YEARS.
NVIR E L LTH SPECCST, DAT ISSU D
04DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS 4PERTY INFORMATION
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Name: `" ? Subdivision Name:
Directions to property: 1 -1 1
t ft,(.-) Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# �^
Road Name: t 1 L �f _ c ' �) zip:;
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building pem-tit.
(In compliance with Article 11 of G.S. Chapter 30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r 1 f PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
"ENVIRONMENTA�JIEALTH SPECIALIST DA ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
L.
RESIDENTIALCIFICATION: BUILDING TYPE #BEDROOMS #BATHS --/— # OCCUPANTS Z GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) L> NEW SITE REPAIR SITE
I
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �_ LINEAR Fr.
OTHER
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REQUIRED SITE MODIFICATIONS/CONDITIONS: so,
IMPROVEMENT PERMIT LAYOUT*Fl.QPRUVED EFFLUENT FILTERia. *RIEER(S) IF 611 11i=LO.! FIf4ISIt?:D GRADE
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oor
**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)751—B760
OPERATION PERMIT
SYSTEM INSTALLED BY:
41-,
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49D f
AUTHORIZATION NO. Z'Q— OPERATION PERMIT BY
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TH S M DESCRIBE AB
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL TE]
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
I
DATE:
IAS BEEN INSTALLED IN COMPLIANCE
BUT SHALL IN NO WAY„ BE TAKEN AS A
67(oa
706 //,OD
' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME a -r L� -:f -e- /--)PHONE NUMBER
ADDRESS SUBDIVISION NAME
/'% C_ LOT #
DIRECTIONS TO SITE C, `f W
p
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER o P "J
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 2
TYPE WATER SUPPLY ALL, SPECIFY PROBLEM OCCURRING'---
DATE REQUESTED �-`)'___ INFORMATION TAKEN BY__�
This is to cerpty that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93