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275 Madison Rd _ . _ . _ _ _ .,z , �... �, . ✓,.. ,. : .,� _ _ _ , -� �r .. , r �'Wa 4'etw'i� w'^+v� �-'�„ .a n'SI""sisti�'v;�:y��a.r ��.h, x. .�;1i*y_ � . .r -,>r. ,^,��y.� , + ��v�'.t-..a � Permittee's� �/� DAVIE COUNTY HEALTH DEPARTMENT � � � ,_Na�e:ec.- • ������5'=` �i'%%�t'!`� � Environmental Health Section PROPERTY INFOR TION e3 � �. � ,� .,. i—T- P.O:Box 848 .i!� 1' �,/ _ ,� �recdons'to property��� .���'�,aG'�i � �F` Mocksville;NC 27028 Subdivision Name: .�� / � ,. .. _�_ Phone#:336-751-8760 _; Section: Lot: AUTHORIZATION FOR WASTEWAT�R Tax Office PIN:# . SYSTEM CONSTRUCTION � - ,�, , . ��/�j . < ALTTHORIZATION NO: d'w����� A � Road Narr6'�!Gr /�.$d/� Zi _ P� **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Emironmental Health Section prior ` to issuance of any Building Pemuts:This Fom�/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Perrnits. � � (ln compliance with Article l l of G.S.Chapter 130A;Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems) � . . , „ j� � ''` ,*';� � —��. ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ��,..'`��t�f',�r°���.�'�:/'� ,�� � �),S'�J IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEAL7'H SPECIALIST DATE ISSUED • RESIDENTIAL SPECIFICATION:BUILDING TYPE � #BEUROOMS�#BATHS�#OCCUPANTS / GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY 1'l'PE #PEOPLE #PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No ' \`LOT SIZE `TYPE WATER SUPPLY r�° t�� DESIGN WASTEWATER FLOW(GPD)�NEW SITE REPAIR SITE � SYSTEM SPECIFiCATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ' ��/ROCK DEPTH J�LINEAR FT.� � _ OTHER ' ' REQUIRED SITE MODIFICATIONS/CONDITIONS: '` ` IMPROVEMENT PERMIT LAYOUT - � i . ,, : , , - � 1 �1 : ._-- w� , . -�'� **CONTACT REP.�E`S�NT{TIVE OF T�IE DAVIE COUNTY HEAL AL INSPECTION OF THIS SYSTEM gg 4•zn_o•�tn,A,y� nR 1;(�-'1:30 P.M:ON THE DA F I �.I� Tjf�I TEL PHONE#IS (336)751-8760. ' OPERATION PERMIT ,�/(J` C I SY r' r / 1�� J,�„�o�J��n:r�' ; - _ /� � . � ,. , , ,: _ AUTHORIZATION NO.C���OPERATION PERMIT BY: � DATE: •'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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. �o����> -C,�.��.`-�� 3� � �� �� p� Call rn,tl�Gti Bi• t� , =: � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTIO w �'��'"� i� �{ � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 'NAM � L��� ��' PHONE NUMBER �9� U�a�� � ADDRESS � � S G�CCC Srl/� i��•�'� SUBDIVISION NAME d�l'd.�� �' a�Qo�� LOT# DIRECTIONS TO SITE (� l 1��� ' i����L��/L ��• C I vuK �i. !'ha:I b�,l Z S� ��"1'��w �? ►�tk _ ,d.���kr � DATE SYSTEM INSTALLED ��-M?o•s NAME SYSTEM INSTALLED UNDER Ca,�-t S TYPE FACILITY NI�K,�a�t— NUMBER BEDROOMS � NUMBER PEOPLE SERVED TYPE WATER SUPPLY G`�� SPECIFY PROBLEM OCCURRINGi:�s�Y��' � 1�at� S�� ��,o �t � ��� �'��s-� � 0-03� M DATE REQUESTED 3 l INFORMATION TAKEN BY (�r� Thi�is to wrti(y that th�information provided is con�ct to tho best of my knowledys,and that und�rstand I sponsible}or all chargss(ncunsd(rom thia applicetion. � SIGNATURE OF OWNER OR AUTHORIZED AGENT � Rw.��93 n/J� 1/ � �' ` .�f4 /1 �� /�/ �� / cndnw Ca�S f cr►�n� �r�- r , h � DAVIE COUNTY HEALTH DEPARTMENT ��- � . (Septic Tank) Improvements Permit and.Certificate of Completion "''' � (Ground Absorption Sewage�isposal System - G.S. Chap r 130-Article....13C�� OWNER OR G'ONTR�Z�`OR '. .. .'+,. ,►!!w.•.,. ►*,..c:.�' ��?�` � �DATE :!�'�l���iji -ERMIT �.,�. .�-�� : � ,. �To LOCATION�, �'"� � �'�"e'` � r�w:s r – .Sc}. lr . ` 3 3 3 i S.R. N0. SUBDIVISION NAME �S�/t/� LOT N0. -�-" SECTION OR BLOCK N0. HOUSE MOBILE HOME BUSINESS ❑ House Trailer 800 Gal. 400 Sq. Ft. N0. BEDROOMS � N0. BATHROOMS edroom House 0 al. 6 S Ft ..��--.-� .�.Q�.�,,,�,.c.,�, GARBAGE DISPOSAL UNIT YES ❑ NO ['�"�� Three Be r c�o o'm Hous �,900 Ga l�.�900� F t�. AUTO. DISHWASHER , YES � NO 0 Four Bedroom House 1000 GaT: 1200 Sq. Ft. AUTO. WASH. MACHINE YES �NO ❑ SITE SUITABLE YES �N ❑ , � S I ZE OF TANK o o ga l. � / �� ��� � ` ,ru�'�S' /� �D G:��' .��t�� Y` � :�,.�., . ° � NITRIFICATION FIELD�_ (n � s . ft. '�1+��"` � r yA �`��' � ,� l't��'.S, � �"'� � ��f• ,� � • � bEPTH OF STONE IN�LINES s �---`�`..�� /�� !�';1 ,�"�t �� �' r� rr.3'� ,�r�, ,,�,�e�:�r Q�"- +�; ,S � ,�` ,� . � � . WATER SUPPLY: � Individual Public ❑ f �'; r„��,� ,t� r►l,� c•� a'�.� S� �+r�r�� . � .�.. � � r` ._ � ,r,9 .� IMPROVEMENTS PERMIT BY. . � INSTALLED BY y�1.6f C%"��%i�-ts._-,�. �-y� i %—� � , CERTIFICATE OF COMPLETI0�1 By „"`�,�` . , • _ Date ��`"�'�' ��' (8/16/73) *Construction must com with all^ other applicable State and local regulations ' LOT AREA' „ ,�, .,,..,.,,,�...�.:. .....�..,�,..-�^~"�""""'"'"""- ��.,... :,.,,..»�.,..�._ �,.,,.., w„„�- ,,,,"'.,-�-..�."w" ,,,�,,.,.�....,......�,.w,r.,»�.»�.�,�.�..�'t,:�.�:��.�.,�:.«....�.:.....:�.. ,..��......�:....:.., _.�.:.�...A��. .w,.,„ .�.,....,,,,,,.a„ ' ,,..��ee��'' �'V� .. r.14a�w.���,�� ' e a��..amr.�M ♦ yyMM''''�� . . . . . ^^�M�M�F.�wrY��M�wFMMw`MIW+WM� .n..Muer`wrT' . µ d. .��. . . . � . . , . . . . . . . . .. J � - _. r� �.� � . . .. . . . .... :' ' . . 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