249 Liberty Church Rd 0" u1!' >S
AUTHORIZ�ION NO: DAVIE COUNTY HEALTH DEPAR}I'MENT
I
Environmental Health Section PROPERTY INFORMATIO
Permittee's '''p P.O.Box 848
Name: N F�QLbWIt}'!� 'Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property:' H 0 q lonl� "ta Section: Lot:
AUTHORIZATION FOR
(20 rla OS�< WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# - -
p�1 Road Name:L1B4ma'a Zi M?
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**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$.'Chapter 130A,Wastewater Systems,Section.1900 S6 age'-Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r- ,5 � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVI OENVI O�LTH S ECIfKF.I TS ECIA T DATE ISSUED
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DAME COUNTY HEALTH DEPARTMENT ;
1371 IMPROVEMENT AND OPERATION P,�R.MITS PROPERTY INFORMATIO
P� rrleae's
Nall�►�I l .sjme..` o Subdivision Name:
Difectioiis to property: 1ju,q (ocl*J Section: Lot:
IMPROVEMENT
a" 1 C t 1 .? f 6?�'r% :'1� PERMIT Tax Office PIN:#
7 Road Name �� Zip o-
**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 1 I of G:S:Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
"7 � l ., ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVII(O LTH SPECI T DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE }K)5 #BEDROOMS 3 #BATHS-3 #OCCUPANTS_�GARBAGE DISPOSAL:Yes or No
COMMERCIALSPECIFICATION:IFFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE��CRC✓fYPE WATER SUPPLY WC-L4- DESIGN WASTEWATER FLOW(GPD)�� NEW SITE REPAIR SITE ~
SYSTEM SPECIFICATIONS: TANK SIZE 1222GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH ELINEAR FT. �
OTHER 47�.3i(L�be7T�JAjo.G
REQUIRED SITE MODIFICATIONS/CONDITIONS: I LEEP 5' Dr F -Sol N(�6 rC�P `��f OFF t,•)C--Lt—
IMPROVEMENT PERMIT LAYOUT
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"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: /G=
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13'71 � �J
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:_4's C�
"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)
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DAVIE COUNTY HEALTH DEPARTMENT ' '
W IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATIO W
Pdmittee's
Subdivision Name:
``,.:.,:Diiections to property: i,��,,..'tl, G '1`� `�.5 Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
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Road Name: -181WCd kh Zip- 02-9
**NOTE**This Improvement Permit DOES NOT authorize the constriction 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 '
ENVIRONIGI HEALTH SPECIALI T DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
t INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS 3 #BATHS-3 #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL^SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZEa,AcR05TYPE WATER SUPPLY WG�- DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE t �GAL. PUMP TANK GAL. TRENCH WIDTH 3lo R DEPTH LINEAR FT. 3
OTHER 0 r-Zn0'1 bOr 1 CA �o.G
REQUIRED SITE MODIFICATIONS/CONDITIONS: E�� S' �� 'J�1(_5?�NCSS pCCa-:P ��' Q�F L.It.Lt_
IMPROVEMENT PERMIT LAYOUT
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"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 ��` 4QL/ „SYSTEM INSTALLED BY: 142b ,C6 �
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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 I1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ah\y%,1 y%, 1PeL_L_, _S PHONE NUMBER
ADDRESS Z`I L"r Cil . j SUBDIVISION NAME
yywC,a ,l(C Y1 C LOT#
DIRECTIONS TO SITE �e to E W+- �-
DATE SYSTEM INSTALLED 01,61 NAME SYSTEM INSTALLED UNER
TYPE FACILITYNUMBER BEDROOMS .3 UMBER PEOPLE SERVED �•
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING Yj 7y-, lZee�-S
DATE REQUESTED Sr g'9 INFORMATION TAKEN BY�
This is to certify that the information provided is correct to the best of my knowledg d that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGEN
Rev.1193