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1-IORIZATION NO: 2 01 4A DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section PROPERTY INFORMATION
Permittee's /��� � J P.O. Box 848
Name: ( / r:at/f ' !%�/t%�L' Mocksville, NC 27028 Subdivision Name:
/ Phone # 336-751-8760
Directions to property: �`, —;;. Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen -nits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
20 It DAVIE COUNTY HEALTH DEPARTMENT �G{ � � Z� U Z--
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
,Nanie:
`Directions to property: +�t� ,•'� ' . '�. <, '
Subdivision Name:
Secti
Lot:
IMPROVEMENT
PERMIT 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
constructionlinstallation 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)
***Nninrv..*** Tm.q PF.RMiT i.Q Ci1Rw..rT Tn RF.VnrATinN w CiTF.
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS e::5Z _ # BATHS '7— # 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
i //1//SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �I'J ROCK DEPTI� LINEAR
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER*
S'v);(� �;nC
FINISHED GRADE-*
"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 O� INSTALLATION. TELEPHONE # IS��C41Wi�-W.1I
(635) 751-13760
OPERATION PERMIT
SYSTEM INS LED BY: _L✓
AUTHORIZATION N 0 `" OPERATION PERMIT BY: L��L%/ DATE:
"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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
NAM
ADD
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
/QII-ek-C .e
PHONE NUMBER
BDIVISION NAME
W
cr
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED
'INFORMATION TAKEN BY R55
This is to certify 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. 1193