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AUTHORIZ'A`fIO1v NO 9 0 DAVIE COUNTY HEALTH DEPARTMENTet
~
Environmental Health Section PROPERTY INFORMATION
Permittee,� �' P.O.Box 848
Name. rrr�tS / ��/ '� ✓ >., , Mocksville,NC 27028 Subdivision Name:
,•, Phone# 336-751-8760
Directions to property:. .16, r' Section: Lot:
14 AUTHORIZATION FOR
✓ ✓,�� " ��`I ,%,`,-tS ,ij �f WASTEWATER Tax Office PIN:# -
1,4
f `� 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-Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for.Building Permits:
(In c pliance with Article 11:of G.S.Chapter 130A,.Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
y� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
F ',""°'-s: ,.x ` � ,R:7. C..4,.� v a.r yio �'. .s .;, {•- ` d
` . � VIE C UNTY HEALTH DEPARTMENT �-?. .1��, .
�fir' o d� �.
y ; IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
. ermitf // ✓� v R T
L t 'Name: 1 '+' rJ� �,if ' Subdivision Name:
A Diiections,toTioperty: .r, _.rn` �° < Section: Lot:
r v 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
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) '(
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANSOR THE jf yid ,� -7'").. �..f, SYSTEM CONTRACTORINTENDED USE CHANGE.YOUR MUST SE THIS PERMIT BEFORE TER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.
'1. RESIDE. .-
NTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS_, #BATHS�_#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)cv..AD NEW SITE REPAIR SITEy
SYSTEM SPECIFICATIONS: TANK SW_ r!?/�-GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1t� LINEAR FT.j2j_)_
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*APPROVED EFFLUENT FILTER* *RISER(S) IF 6" BELOW FINISHED GRADE*
Us
So
Pooj
**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(Ru)(681tv6ax`
336)751—a760
OPERATION PERMIT
SYSTEM INSTALLED BY: i �M �1
I 4�k 'IAT"'_
LQo.-s T
ST Po�� k Co x3G'x24"
4101
AUTHORIZATION NOA?,00 OPERATION PERMIT BY: �W' DATE: _e 1/4)
**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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 1
NAME /%`fill`s /Y��` � PHONE NUMBER !`l
ADDRESS W SUBDIVISION NAME (�
LOT #
1�
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
�o
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.1/93
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