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.rAtJ'i,�IORIZATION NO. 86 9A
Environmental
COUNTY HEALTH DEPARTMENT '- 72, 0/ '
.� .
Environmental Health Section PROPERTY INFORMATION
,Permittee's': P.O:Box 848
Name:'` s Mocksville,NC 27028' Subdivision Name:
/ ,.�� ,,/►,/! Phone# 336-751-8760
Directions to property:. Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SY EM CONSTRUC ION / ax Office PIN:# -
-
d✓. ad Name: Zip:
**NOTE**This Authorization for Wastewater System Cons ction MUST BE ISSUED by Davie County Environmental Health Section prior
y • g be presented to the Davie County Building Inspections
to issuance of an Butldin Perrtuts:This Fonn/Aut onzation Number should
Office when applying for Building Permits.
(in corn iance with Article l l of G.S.Chapter 130A,,Wastewater Systems,Section'.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR APERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
� �� -�"� � "yrs`""= f itf-^e.y�<p:mx, j y,,e_'u 1,. It-'.. 2 ,., 1},r `yq c'c,� ac.'ifar �y;,r .trra .,=fr.tr 't,k - .. .4•a -;.i ,.aa.,r,�•,T.,k T „•;.>.
6 9 DAVIE COUNTY HEALTH DEPARTMENT �� �`�" �"3_ •U / y✓
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
f s y•,
Name:' V�' 1r1'l/, Subdivision Name:
A
r';Du'ections to property:x/5-7 /f"' T u''r' Section: Lot:
�✓ IlVIPROVEMENT
�';r /i, ' PERMIT Y j Tax Office PIN:# _
Zi oad Name:
l� P•
**NOTE**This Improvement Permit DOES NOT authori a construction or installation o a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYS M 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
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 _#BATHS /�#OCCUPANTS < GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:/Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TANK GAL. 'TRENCH WIDTH'� oo�ROCK DEPTH/�_r LINEAR Ff:'
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT ridn EFFLUENT FILTER* *RISER(S) IF 6" BELOW FINISHED GRADE*
r
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH D AR ENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF ST LATION.TELEPHONE#IS(X9)63X8 MX
(&36)751-8760
OPERATION PERMIT
SYSTE INS LED BY:
i
ti
AUTHORIZATION NO. �`OPERATION PERMIT BY: 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 ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 0996(Revised)
► DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION 1,
APPLICATION FOR IMPROVEMENT P, RMIT(REPAIR) u 1
NAME �;! �/lh �GGi'`Jlr?.� 1� y/� PHONE NUMBER
ADDRESS f � % SUBDIVISION NAME
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
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