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, �AUTHORIZATION NO � � � �AVIE CQUNTY HEALTH DEPARTMENT ' f�;;,�� �--�=�
. � Environmental Health Section PROPERTY INFO/�RM TION ,
Permittee s P.O. Box 848 dC_' �:_�—v Z�
- . �,���R = , . ._ -
_V� n�� � Mocksville, NC 27028 ;, Subdivision Name:
Name;. .� - �;ni ''. �. t,�,�C t. ��i
- - ,. ` � Phone # 336-751-8760
. Directions to propeRy: ���� ���^��� ` Section: Lot:
AUTHORIZATION FOR
`�{.a . ---� ..r� �- . ,J ""�-, �1�3� :l.�G`•'�t�s • ,;WASTEWATER Tax Office PIN:#
� V �� r? � _ ' ' _ .
• -� , t
SYSTEM CONSTRUCTION
� Road Nam�e��. l-iJr�i�4� ��v��w Zip: °'2`?�2R
, , , : , „ _. �
**NOT'E** This Authoriiation for VJastewater Sysfem Consuuction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building�Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections
` Office when applying for Building Permits.' - ;.
'(ln compliance,.wi Article l l:of G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ��'
�-' '' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,. '� , : - 3 L� t�.Z IS VALID FOR A PERIOD OF FIVE YEARS. ;` ,,
�'': ENVIR N - HEALTH S,�ECIALIST -� DA E ISSUED
_ •\ { 9'• -,_ - -�-* -_�' f - `+f �` ri_"Y(• 'e•''2 {'4 . `iL i i y �[�.�j -//r!` {.�j''-'v (" �+r.-.y...
fr DAVIE COUNTY HEALTH. DEPARTMENT
IMPROVtMENT AND OPERATION PERMITS PROPERTY INFOR (MATION
Per�nittee's 7 v Z...
Nanei, 10nS Subdivision Name:
Directions to property: `+ ~1 t ��+^:'4�t= Section: Lot:
IMPROVEMENT
'M , V 4: ,-� �,. r :I'r� 1 c;• PERMIT Tax Office PIN:# - -
r�
Road Name: 4w r .+� a' {' tt J, ✓ k
**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 l I of G.S. Chapter 130A;,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVI ONME AZ'HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
v � INSTALLING THE SYSTEM.
RESIDENTIA
L SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS 4 ? # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITYTYPE_ # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZES � 6 HYPE WATER SUPPLY U� nY DESIGN WASTEWATER FLOW (GPD) NEW SITE - REPAIR SITE "
SYSTEM SPECIFICATIONS: TANK SIZES ^^GAL. PUMP TANK GAL. TRENCH WIDTH, ROCK DEPTH l LINEAR FT.
OTHER �` 4J % STCA � 1�T1 t�� iC is S
REQUIRED SITE MODIFICATIONS/CONDITIONS:"
IMPROVEMENT PERMIT LAYOUT APPROVED EFFLUENT F1LfTER**R-j_SER,tS) I �� BELOW FINISHED GRADE*
co�a�l`I1'0.� Q,�7> =T-
00L)S6 .2
U
U.
W
**CONTACT A REPRESENTATIVE OF THE DAVIE CO AL PA ENT FOR FINAL INSPECTI, YSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON TH DA F ST ATION. TELEPHONE # i��7fi4]
OPERATION PERMIT uv
SYSTEM \1TA\LED\YV_j�0 1
-)AJ
2s
d f�
AUTHORIZATION NO.2- OPERATION PE IT
" l7 2
**THE ISSUANCE OF THIS OPERATION PERMIT SHAL INDI TE AT SYSTEM DESCRIBED ABOVE HAS B E S LED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .19 0.1 SE AGE A NT AND DISPOSAL SYSTEMS", BUT S IN NO WAY BE TAKEN AS A
FP
GUARANTEE THAT THE SYSTEM WILL FUNCTION SA FAC GRIL FOR NY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised) ,
i
- NAM
DIRECTIONS TO
DATE SYSTEM IN
TYPE FACILITY
TYPE WATER SUPPLY
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) O
4, �—//rte PHONE NUMBER-
A,/
UMBER BEDROOM
BDIVISION NAME
ALLED UNDER
NUMBER PEOPLE SERVED
PECIFY PROBLEM OCCURRI
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.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193