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+AUTHDAVIE COUNTY NO: HEALTH DEPARTMENT .Y 3'°�� _: .� 1a-
'Environmental Health Section PROPERTY INFORMATION
Permivee s_'._ P.O.Box 848
-L E 111 t A
Name ^� �: Mocksville,NC 27028 Subdivision Name:
Phone# 336-751=8760..` '
Directions to property: � L.�L:, w -�—'' Section: Lot:
AUTHORIZATION FOR
f.. . . WASTEWAT
T a) "j l�" ER SYSTEM CONSTRUCTION ' Tax Office PIN:#
Roadtale:. - zip;-
n
**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 complianc wi icle 11 of G.S.Chapter;130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER•CONSTRUCTION
, I OZ IS VALID FOR A PERIOD OF FIVE.WARS.
ENVIR N ALTH PEC LI$T, DA EIS UED
b,""j,f .yp yr. Y'- rc� ^. , .`a3. V`i'.: :';3 t i� w - ,.�,,.+w.'.Y.fu .'' ! h -•, Y' "{ - `' �j [ "� �:. .. y'wh �" A'y ./'{ •, ',; '). . 7
DAVIE CQUNTY HEALTH DEPARTMENT (%"+I `(3 ' °
79 ...�
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee;..�
i•1�tA'Y`
Name*' Subdivision Name:
Direct ns to property: I4OL �t^3 �. �1 �' Section: Lot:.
IMPROVEMENT
f, IL PERMTT
;
Tax Office PIN:#
f.
1.
t �l,a 1� s!l-
--
Roada e. Zip: I.
4
1
**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 comphatice 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
ENVIR(SNME EALTH PEC ALIS ` DA
I SUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE .
_ -,
INSTALLING THE SYSTEM.
y
RESIDENTIAL SPECIFICATION: BUILDING TYPE t # BEDROOMS sZ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL' SPECIFICATION: FACILITYTYYP��,E'' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
�(C%
LOT SIZE'e` TYPE WATER SUPPLYCWL DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE u^+ GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH l Z LINEAR FT. 2o�)
1
.,.: OTHER J 3�X
A G0r TZ) 12 "
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUTyEpI?RROVED EFFLU .FILTERS ISER(S) IF G•' BELOW FINISHED 61t(DE*'
OU_-) 'TA-31t
Kr_>
D
DCHD 05/96 (Revised)
�,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME Ela-.v.c W: 11:amI PHONE NUMBER 99f-4240 wrl(-
-je1 - 2.759 116 -f -
ADDRESS 4;LA 4 kkw j Q'O 1 S Qdu- 7,7 oo1. SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE Lq V - T• 24. 801 S - A draft r. T-4 Lye 11" V►r&CO
DATE SYSTEM INSTALLED — NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS Z NUMBER PEOPLE SERVED -3
TYPE WATER SUPPLY CAUtnTN SPECIFY PROBLEM OCCURRING olk I-N%Q AAG Ciev.a
Q1cD 6-ytw%je du".y - (q) Q& r- 12y6j ��ce.)-l,u�ab 1� rW1A*-4fUJL +- d nw 1 mes
DATE REQUESTED 3-2.0-'>Z— 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