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AUTHORIZATION NO;'�. DAVIE C UNTY HEALTH.DEPARTMENT
'_ "'' Environmental Healtti Section PROPERTY INFORMATION
Permittee c P.O. Box 848`
Name: Mocksville, NC 27028 Subdivision Name:
Phone # 336-7.51-8760 .
Directions to property: tA� Section: :� Lot: J
AUTHORIZATION FOR
WASTEWATER 'Tax Office PIN:# - -
SYSTEM CONSTRUCTION ���y%22 i
Road Name: yDl r.' -,
**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 compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
3 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION,
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED '
DAVIE OU
16 3 ,,, NTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
PermittEe's ` , /
r ' hiame:a' i'x Subdivision Name: �D, 1P
Directions to^property: hel ✓e Section: ? Lot: ;
IMPROVEMENT
PERMIT Tax Office PIN:# -- n
Road Nat • Ro D i r p�'p� a2 rI o0(0
**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/igstallafion of a system or the issuance of a building permit
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
# BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
# PEOPLE/SHIFT
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)
# SEATS INDUSTRIAL WASTE: Yes or No
_ NEW SITE REPAIR SITE l/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH —?,(4 ROCK DEPTH � /LINEAR FT. /S
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r
**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)751-8760.
OPERATION PERMIT
AUTHORIZATION NO. l h z OPERATION PERMIT BY:
rE INSTALLED BY: IRNn IMn io,
�Q
a;j
V
DATE:
/" /97
**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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
� � i i•• 4� 11: � J �v
' DAVIEOUNTY HEALTH DEPARTMENT
TMPRO�EMENT AND OPERATION PERMITS
PROPERTY INFORMATION
r NPearmmelt: tee's_, . Subdivision Name: 1/4
D T
Directions tb property: 0 rhe/ Section: ? Lot:
IMPROVEMENT e
PERMIT Tax Office PIN:#
Rnnrl
**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 permit.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
# BATHS # OCCUPANTS 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) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH' -.F < ROCK DEPTH' �� LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**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)751-8760.
OPERATION PERMIT
,Q �¢L
\a1.
qk tQ
SYSTEM INSTALLED BY:�►a�V
� Q
0
AUTHORIZATION NO. �b OPERATION PERMIT BY: �Y `' DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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. t
�i
DCHD 05/96 (Revised)
s !'i
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME CiGu l/�0 PHONE NUMBER "1 q
11
ADDRESS I �. 0�� r �� - SUBDIVISION NAME
A - I ?
DIRECTIONS TO SITE
BDIVISION LOT #
DATE SYSTEM INSTALLED ;:z 5�-7�' "X '
NAME SYSTEM INSTALLED UNDER ?
SPECIFY PROBLEMS OCCURRING -M e' 'aQ41n
DATE REQUESTED I INFORMATION TAKEN BY
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