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226 Walt Wilson Rd ,, ,, , .,,. .. ,�.« > ,,,�,��_., ,�, � , h ,,, ;.. �r�.-��,:.,.- ,r•;. .�.-� . � ..� ��� ,- „. . - , �. � . � .�,� <:�,� � , . ' � � . ` . ee s �� ` . � � ��V][lE C��1N�'� ��A1L�'H g➢��A�2�'1VIENZ'� '.' ,; �li�C� : a e:' ���`��'',�a�'�. .�������+'��,�r�`�'� �" Environmenta�l Health Section , ' PROPERTY INFORMATION - f� 1... . . ? . . , • .q .. ,: �,.. . . • . P.O. Box 84�'� • . . . ��� � ' ' �Directions to ro ert r� ��� . �'� � � � � '•� � x�� ,� , . , � �, , •. �'�8' ^•� �. P P Y. N�� ' � �l` �' f �0�%J dMocksville; NC 2�7�28 ;Subdivision Name: , � Phone#: 336 751=8760 M " .`� " Section< � . Lot: ���e� � -� �. A��:� _ �� ;�� .. . ' . . " ` ° �• AUTHORIZATION�FOIt " � �. , � , ' WASTEWATER . . : Taz Office PIN:# _ . . SYSTF.M CONSTRUCTION . . � " . ,r�.. . . � . ,, � , :AUTHORIZATION NO: ��'�� q �: ' " .... R�ad'Name, �r Zi , v . , m_ - p: - r ** **' . . ... s, . , • ' Countv.,Environmental Health Section prior � ' NOTE . 1'his Auth�nzation for Wastewater System'Consfruction MUST BE"I:SSUED by,'the Dayie � t�issuance of any IBuilding Perrrut.;-This Fonn/Authqnz�t�on Numher should be presented to,the Dav�e County Building Inspections, , . .�,. ` ' Office�when a 1 in for Builcling Permits'. " �� ' - PP Y �. , z�; _ (ln compliance with Arfide 11"of G.S.Chapter 1.30A�Wastewater System�,Section.1900 Sewage Treatment.and Disposal Systems) ' . �.�� ." �,,.�� � � - ' _ . . , . ; ' �� .,�.,,�,�r�;�'� �� ,'� �� ���,�.�r' ��� � ***NOTICE*.**,7'HISAUTH()RIZATION�FORWASTEWATERCONSTRUCTION . r�'.���J�,��`� t'k'�;°'" . ��.'`'�;*`� i .t���'�'.s="�`�.a' � s�f;,�.s `��,'� � �� . ' . �`�+�` " 'a, IS YALID FOR.A PERIOD OF FIVE YEARS: ��.. ,., ' . � ., • _. ' ENVIROVMENTA'�'L,HEALTH SPECIALIST Dr1TE 1SS�.�ED " . ' ,� •. � : , c � " a ' , �. . ;. , „ : , . � • • 'RESIDENTIAL SPECIFICATION:BUILDINGTYPE- ��� #BEllROOMS l�4 �#BATHS .,� #OCCUPANTS � GARBAGE`DISPOSAL:Yes or No COMMERCIAL SPECIFICATION:`FACILITY TYPE •#PEOPLE #k PEOPLE/SHIFT #`SEATS:� �,INDUSTRIAL WASTE Yes.or No, � , LOT SIZE + TYPE WATER-SUPPLY DESIGN V✓A - ti .j . - �: � STEWATER FI?OW(GPD) t`��� NEW SITE � REPAIR•SITE '� - . ; L x . - „ ;. SXSTEM,SPECIFICATIONS: TANK SIZE. GAL. .PUMP TANK GAL TRENCH WIDTH��'� f ROCK DEPTH� LINEAR FT a�k�� .' :. . , . , , . , < OTHER . . ,. , . . . . . . . . , �, ., , . y. � , . , , QUIRED SITE�MODIFICATIONi � 1 ` '• . �; . . . i RE S/CONDITIONS: ' � r � _ -, . . .., . . � . ,, ' °IMPROVEMENT:PERMIT'LAYOUT' , •... . , . ;`'. `; � : L . �� . . . . . •. , . � . . ; . " ; • `. - ' ,: ,' � � .�: . . a: . � . . , . , ; , . . . : � . , , . . , E, . + . ' . , . : . . � .. . . . .' W" . � .. .. . . . .'� �. . . . . . , . . . � .. .. . . . �. . . . ' . . , � , � ,. . .. . . dr � , � . r . �. . . .- . }'' . . _ ' � ' '. .v , . � r� � .. � . � ., • . . .. .. . . . . . �: . r S , � . . . . .. . . �.. . , . , � ' �- �� - n' � ::. . � .. ' i. ' � - , ' . . • . ." . . . .;.. .. . �... ' �. . ;. ' _ • ;; **CONTAGT`Q REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT'FOR FINAL INSPECTION OF THIS�SYSTEM � ' ` ,; BETWEEN 8:30-9;30 A.NI.OR 1:00-1:30 P:M.ON THE DAY OF INSTALLATION,TELEPHONE#IS (336)?51-8760:: ; s. . ; ,: .,�, : ," ' �. . - ; � OPERATION PERMIT . � - : , �� . �!9"'� . . , ,. . SYSTEM INSTAL'LED BY' . , � .+ . , . . , � ., , : „ . „ . � � . . '. . � �� " � � J.� . • �. •- -� ; ,. '. . .. . � . '� � :. . . . " ..r. .. .. � , . . . , . . � .� . . �� � - . . .� � . � . _. . ' � . . . _. , �_ -�. � , . .�,.. . . .. ., , . . . .. . , . . . - . .. ' � . . � , �, �� , ., e � � . .. � � , . ' .. . ... � . . ' ,. ' � � -. , . . . . . , . , , - . , . . . . . . . . . . , . . -,. . . . . , , _ ,. - . . . . . � . . .. . � �, . �. . �. , . ., . . . . ., . . / '- �' � , ' . ' ' ,. _ � . . . . . . . ., .. . .,. . .. . . . . , . . . . . .. .. - . . . , _. . ., . . . . . ` ` . . , . . , .. . , . � .. .>. . . . �- . . . AUTHORIZATION NO.���OP6RATION PERMIT BY: r 1 i '., DATE:, `v�✓�d ~`r ,., � . , **THE ISSUANCE OF THIS OPERATION.PERMIT SHALL INDICATE THAT THE,SYSTEM DESCRIBEDABOVE�HAS BEEN INSTALLED IN COMPLIANCE 4: ' " � WITH ARTICLE�11 OF G.S.CHAPTER 130A,SECTION 1900y"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 TIIv1E. . �'' . - � ;� ' DCHD 07102(Revised)� ,' � � " - � � � , � � � - ' ' � ` �� � � � , , _ , ' r. , , „ . , , , . s� / r � , . . ' ' . . i � , o�.��� , ����� � r 4 . 4 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION /�G/� /rf�.. ^.� ' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) . / 7 / p NAME � G4 �/ �/l PHONE NUMBER `.���� / L ADDRESS��✓��.�(//41-���l/��v/—r� � SUBDIVISION NAME LOT # DIRECTIONS TO SITE t��2 T- � Li(/ . ��c� ��Gj�'� —� �iyJ�,rJ�ivS .. DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY T� NUMBER BEDROOMS�__NUMBER PEOPLE SERVED t TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible}or all charges i�curred from this epplication. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93