2600 Farmington Rdk Permittee's 1, DAVIE COUNTY HEALTH DEPARTMENT
Name: ' ': c 4 �' ,,`�-,'..� �'� ` - Environmental Health Section PROPERTY INFORMATION
/ P.O. Box 848
Directions to property: -, t�� Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
/ . AUTHORIZATION FOR Lo
I
Section: t:
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#�
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AUTHORIZATION NO: 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 Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article l 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
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS-/ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE +' TYPE WATER SUPPLY C� DESIGN WASTEWATER FLOW (GPD) i (.� C� NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK ! GAL. TRENCH WIDTH�ROCK DEPTH r LINEAR FT. 1
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
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AUTHORIZATION NO. r–
tO
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ATION PERMIT BY: _
SYSTEM INSTALLED BY: –) [1 `4,r l% q
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 02/02 (Revised) -I') -7 ' < C �� /�
/ <�> ! ..-/v VQ ICP✓ (JC
Perniicfee's j' DAVIE COUNTY HEALTH DEPARTMENT
Name: ! ` ' �`. `,t "`- Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions✓to property:" ) �- �,-! (� Mocksville NC 27028 Subdivision Name:
t; t r Phone #: 336-751-8760
Section: Lot:
— AUTHORIZATION FOR
�, WASTEWATER
_ SYSTEMCONSTRUCTION Tax Office PIN:# -
-
AUTHORIZATION NO: ' Road Name.t � `'„; � .�� tt�,. �•�,
Zip:
**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 FornVAuthorization 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)
J i / , ? �•� ^ i ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS .J # BATHS )- # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
"-f 5 P 3
LOT SIZE � ' uGTYPE WATER SUPPLY CU DESIGN WASTEWATER FLOW (GPD) �� C NEW SITE REPAIR SITEy'
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r, � ,ll fr
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK _GAL. TRENCH WIDTH 3`� ROCK DEPTH LINEAR FT.
f, REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
( t
u bu �ct�
V
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r
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT r �a�bi•� q�7T h
- k `J ' SYSTEM INSTALLED BY: "1
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AUTHORIZATION NO. O 1af•ION PERMIT BY: DATE:
**THE ISSUANCEAF 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.
DCHD 01/02 (Revised) L c) _:TA)110 ;0 e. /n q,3Z,
gill f0
NAME MORI
q -N Z iy6 #Wk. �O/ /V • DkOJ
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTIONr
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) C��h��
2
PHONE NUMBER
91,3-2113
ADDRESS.7600 ��r�ir�,�g-�onl l- ���/�l� SUBDIVISION NAME
DIRECTIONS TO SITE
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Alft
LOT #
Ric he<<
/7 (p u S mme, /riAae -mNl(-
DATE SYSTEM INSTALLEDZ - & NAME SYSTEM INSTALLED UNDER
TYPE FACILITY &&-flW4 NUMBER BEDROOMS NUMBER PEOPLE SERVED
A 1 !)_ -/-.
TYPE WATER SUPPLY (,OUntq SPECIFY PROBLEM OCCURRING 12f l KI A4 u D
f69r�' iNQround Gt�4uf %�i�J. G��O�ih n�;DIS.
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 for all charges incurred from this application.
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SIGNATURE OF
�1�
OF/ OWNER OR AUTHORIZED AGENT /`
Rev. 1193 /I/A J' i w/ P'7 e '
N
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HEALTH DEPARTMENT
ID, C.ERT,.IFICATE�`OF� COMPLETION
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