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Permittee's�' DAVIE COUNTY HEALTH DEPARTMENT
N�me: _ � ; ��<<��e ����'-S Environmental Health Section PROPERTY INFORMATION
' - P.O. Box 848
Directions to ro ert : ` ` ' f ` ' ' r�
, P P Y . ' ` ''' Mocksville, NC 27028 Subdivision Name:
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SYSTF.M CONSTRUCTION Tax Office PIN:# - l;`: _ �t
AUTHORIZATION NO: ��`�'�'��'� A Road Name �f�'�'`� i ����� -�'�' Zi ��i` ,�``
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**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 Pennits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
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� �: -r'� i � ' ` , "' r ' � ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
i' ' '; '�t t{.i � �•../� �;ia!�•'C� �"� •i:f' !`t` L�; �.�' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTI-j'SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE %��� �L #BEllROOMS % #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
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. COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF✓SHIFf '#SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ( � t=' '�DESIGN WASTEWATER FLOW(GPD) �r,� NEW SITE REPAIR SITE �/
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SYSTEM SPECIFICATIONS: TANK SIZE ��`t'� G`AL. PUMP TANK GAL. TRENCH WIDTH `�> t-� ROCK DEPTH %� '�n LINEAR FI'. -r��
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
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AUTHORIZATION NO. �"�� ' OPERATION PERMIT BY _r ��'�./ 4..����'�J f/� �'��,`l L�^CC.:t,./ DATE: ����/ !�v"l U
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•'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
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Permittee's . .. �i. DAVIE COUNTY HEALTH DEPARTMENT
Nr�`me:" r•u;�r��f`f� l���r��-'� . Environmental Health Section PROPERTY INFORMATION
, ' P.O. Box 848 .
Directions to property: ' ` 1�locksville,NC 27028 Subdivision Name:
. - _ Phone#: 336-751-8760 . ,
. ' , Section: Lot:
AUTHORIZATION FOR
, WASTEWATER Tax Office PW:# � ,� ��, t ?. � "` `-
SYSTF,M CONSTRUCTION
.� ���
' AUTHORIZATION NO: ����` ' A Road Name. � ` - fj ' ;� �Zip: �'r`"
**NOTE**T!tis Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pem�its.T'his Fom�/Authorization Number should be presented to the Davie County Building Inspections
Office when applyina for Building Permits.
(ln compliance with Anicle 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems).
,�� ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
'.`. j i, _ ��' ''�: - . IS VALID FOR A PERIOD OF F'IVE YF.ARS.
ENVIRONMENTAL HEALTHSPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS � #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' k SEATS INDUSTRIAL WASTE:Yes or No
/
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) `'� NEW SITE REPAIR SITE
SYSTEM SPECIFICA'1'IONS: TANK SIZE ? GAL. PUMP TANK GAL. TRENCH WIDTH . (l ROCK DEPTH i ��LINEAR FT. �`�a
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OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT � '
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FOR FINAL INSPECI'ION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT �, � t t /
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AUTHORIZATION NO. ��"�-" f �� OPERATION PERMIT BY f� , < 'f C l./�(�� /i �GJ �:C(�-�� DATE: �f� / e
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*"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE .
WITH ARTICLE 11 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS".BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTTON SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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Davie County Health Department
Environmental Health Section Payment Due Now.
PO Box 848 (210 Hospital Street) Please Return a Copy of the Bill with Payment.
Mocksville, NC 27028 Your Check is Your Receipt.
(336)753-6780
Frankie Reavis Account No: 990005550
223 Buck Miller Road Invoice No: 7374
Mocksville, NC 27028 Billing Date: 7/9/2010
Srv Date Service Code ID/ATC# Description Srv Cost Quan. Extended Cost
7/2/2010 SEPTIC-REP-R 3034 A 223 Buck Miller Road-27028 $50.00 1 $50.00
Balance Due Now: $50.00