233 Granada Drive Section B Lot 71_4li
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AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT '140
A Environmental Health Section PROPERTY INFORMATION
Permittee's i f� P.O. Box 848
Name:t..r►`I �'���
Mocksville, NC 27028
Subdivision Name:
Phone # 336-751-8760
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Directions to property: �` Section: B Lot:
AUTHORIZATION FOR
",J WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
(, .A(,)111 rj-1/'0 1 � n,.J `�%nJr' �i < ar3 Cr i Road Name: (':1 �! "A . I 1 �
i 'tip: a, (;~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 Ah Art'
'le l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
1r>, ,M --- "i ! IS VALID FOR A PERIOD OF FIVE YEARS.
NVIIfONMH SPEC ` DATE ISS ED
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' DAVIE Oi1NTY HEALTH DEPARTMENT
TWR C VEMENT AND OPERATION. PERMITS PROPERTY INFORMATION
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Subdivision Name V.
Dections to' property1�� �0�`4 Section Lot:
IMPROVEMENT
Tax Office PIN:#
Road Na�ine .E/ t/ %' ""Zip
**NOTE** This Improvement P"t DOES NOT authorize theconstniction'or installation of a septic tank system or any wastewater system: An :
AUTHORIZATION FORWASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the:
construction/'installation of; system or the. issuance of a -building permit.:
com hai►ce di Article I 1 of G:S. ter I30A, Wastewater Systems-, Section. Sewa a Treatmenrand Disposal Systems)
Chap y g. Po' y
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o »� J ***NOTICE***'THLS,PERMIT IS SUBJECT TO REVOCATION 1F SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER .�+. .
SPECIALIST DATE IS SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
v INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION BUILDING TYPE M i # BEDROOMS' _ #BATHS 2 # OCCUPANTS GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICIATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT • #'SEATS INDUSTRIAL WASTE: Yes or No
IZX:? X1Ii� ._
LOT SIZE .. TYPE WATER SUPPLY 'DESIGN WASTEWATER FLOW (GPD)6c) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE --GAL. PUMP TANKGAL. TRENCH WIDTH, ROCK DEPTH LINEAR FT.
/
. �-
OTHER Z 1a fi•r7
REQUIRED SITE MODIFICATIONS/CONDITIONS:�h ` .c ' "u� ' "' (v
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-**CONTACT A REPRESENTATIVE OP THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM . .
BETWEEN 8:30 - 9:30A.M:'OR 1:00 -, 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS'(336)751-8760.
OPERATION PERMIT` \
SYSTEM INSTALLED BY: W F } l Tb
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1946 DAVIE OUNTY HEALTH DEPARTMENT
IMPR `VEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee s c
Name:
Directions to property(''
I Y r
E fes. 1
IMPROVEMENT
PERMIT
Subdivision Name:
Section: Lot: /
Tax Office PIN:# - -
Road Name: 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 permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
j *'�'�1VU111:L''�'� llilJ YL' KMll 1J JU1fJi:l:l 1 V liL' V VITA11V1V 11' Jl1L'
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
( INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �_ # BEDROOMS �' # BATHS 2- # OCCUPANTS GARBAGE DISPOSAL: Yesr _oo✓i
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
IC!;1
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LOT SIZE TYPE WATER SUPPLY'-- ' DESIGN WASTEWATER FLOW (GPD),. NEW SITE- REPgiK_SIf�'— /
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �(•, ROCK DEPTH � !� LINEAR F r. L
OTHER t/ r-1 r J r7( YL,
REQUIRED SITE MODIFICATIONS/CONDITIONS: rt'i !� `( r ,14A 4! �L (� �() I �� 1 `01— `L l �L
IMPROVEMENT PERMIT LAYOUT
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"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
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SYSTEM INSTALLED BY:
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AUTHORIZATION NO. I OPERATION PERMIT BjC: DESCRIBED AB DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT YSTEM VE 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.
DCHD 05/96 (Revised)
NAM
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION .Z . ti _qq * QQW3
A PLICATION //FOR IMPROVEMENT PERMIT (REPAIR) UV ytJ/��
L(O j�'Oq 5T �PHONE NUMBER
ADDRESS SUBDIVISION NAME
LOT # I
DIRECTIONS/T,O SITE 001f-4-4 , �Sl— oma '5411 "&,Cr> &7 -
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY N NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Cam rY SPECIFY PROBLEM OCCURRING—
DATE REQUESTED V-6 INFORMATION TAKEN BY�
This is to certify that the information provided is correct to the best of my kno�ledge, n that I understand am r
SIGNATURE OF OWNER OR AUTHORIZED AGENT
7/A/Y//Z4-
Rev. 1193
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charges incurred from this application.
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�:UANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THIUUZYM-1P�2-