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' AUTHGRIZATION NO: 0818 DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section PROPERTY INFORMATION �' To,
PeAitteer W \\ P.O.Box 848
Name: �”'
``�� X i tvt".3 Mocksville,NC 27028 Subdivision Name:
Phone.#;704-634-8760
Directions-'to property: S S C Section: Lot:
AUTHORIZATION FOR,
WASTEWATER Tax Office PIN:# - -
�- SYSTEM CONSTRUCTION
IV -N
�l r
�1- VIM _ � CSR Road Name: 5? r S Zip:tet 004
r
**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 11 of G.S.Chapter,130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
.� Q� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
J.N 1 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
- DAVIE COUNTY HEALTH DEPARTMENT ,
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name _ + is tk�.5 Subdivision Name:
Directions to'property: `= Section: Lot:
c IMPROVEMENT
PERMTf Tax Office PIN:# - -
�r, . Road NameZip:;-,Q
**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/mstallation 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
ZAI
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_CSL #BEDROOMS 1 #BATHS _#OCCUPANTS_�_GARBAGE DISPOSAL:Yes oU
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE^`DV �, E WATER SUPPLY l DESIGN WASTEWATER FLOW(GPD) 2 L1 a NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL`. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVE ENT PERMIT LAYOUT
O ,
("Lb V5 �
E
**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(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: Lt n n
lam" ,y
M
Cwx r"
0\9 -\11
AUTHORIZATION No. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TRE 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)
�t't-t'�,...4""`r ., ' ,�� •a� .,fir.� t `"' res;,......... .. --rvq `r;" ti i' t;y`, .;,: ,-k.r ., a "c-, '• 1.��
DAVIE COUNTY HEALTH DEPARTMENT4s� j
IMPROVEMENT.AND OPERATION PERMITS PROPERTY INFORMATION
Subdivision Name:
Directions to,property:. Section: Lot:
EWPROVEMENT
PERMIT
�- - Tax Office PIN:#
Road Name: - -w zip:", - t •
**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
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 o
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE 'S --* ;TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) L. 0 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVE ENT PERMIT LAYOUT
,
ti
I
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
f BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: t1 l�v+�Gtr. N ►1 h
F
AUTHORIZATION NO.� D OPERATION PERMIT BY: ' ' DATE: J'**
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THATSYSTEM DESCRIBED AI�OVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TRE ENT AND DISPOSAL SYSTEMS",I](UT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY-FOR ANY GIVEN PERIOD OF TIME.
i
DCHD 05/96(Revised)
I',0 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME11 °1- 1'I a .Y� PHONE NUMBER
ADDRESS I �� WG1 gD�S SUBDIVISION NAME
LOT # l
DIRECTIONS TO SITE � '��" gd�-5- 2aago-il,
Ulu
DATE SYSTEM INSTALLE ? - NAME SYSTEM INSTALLED UNDER
TYPE FACILITY UMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED / 7 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 responsihlp for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT W I'ItAl �
Rev.1/93