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124 Manchester Ln \1 Y.� -.'� �'. .. �.-��� - �.. . -...4i,.� ..�'`��.. � "-�.� .a.,.�:�.-k ,-,:i:..6 .P,,.'.4 ._�_...,'_. .,w ,��. �r,,.-+1: �� j --::i.a.v,?t��., . `r�, � . ��' .. '.'r-<_,_,- �. .� � . . , . . . : . . ' ,. �����✓:-��� .. ". . F PecTr�ttee's,, , VIE COUNTY HEALTH DEPARTMENT -"Name:`�S�'.����,.�'' .�✓.-r �r �f �� Environmental Health Section ' PROPERTY INFORMATION � ,.... � � . , P�pJ;,$ox 848. �, Directions to property:l-�r'� ��>� ��i�.r��:-�''����jri(ocksville,NC 27028 Subdivision Name: � �y� Phone#: 336-751-8760 �j`�:.°��;,r,r �r;� r.?��,r r''r��.�lf,��r'�%'.%,r, ��/�j���'' Section: Lot: , , � AUTHORIZATION FOR . WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - / AiJTHORIZATION��NO: ��'/ / A Ro�d/N�ame:�'���5'�`'`�'NZ►p. **NOTE**This Authorization for.Wastewater System Construction MUST BE ISSUED by theDavie County Environmental Health Section prior to issuance of any Building Permi[s.This Forn�/Authorization Number should be presented to the Davie Counry Building Inspections Office when applying for Building PeRnits. (ln compliance with Artide l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) f j 'r � ���f�'"'``-�-�-'�.�, ***NOTICE***.THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �,.'��`' �-+ /j�f,�''�� <=�"" .;�/�""f�'�.%r ...''IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED i :� '� RESIDENTIAL SPECIFICATION:BUILDING TYPE � #BEllROOMS�#BATHS � #OCCUPANTS GARBAGE DISPOSAL:Yes or No , COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTEc Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)/gd NEW SITE REPAIR SITE 1� .. SYSTEM SPECIFICATIONS:. TANK SIZE GAL. PUMP TAN34- GAL. TRENCH WIDTH �v ROCK DEPTH��✓LINEAR FI'..�G�U _ : OTHER , , , � REQUIRED SITE MODIFICATTONS/CONDITIONS: ' f" , IMPROVEMENT PERMIT LAYOUT •'' �' - �� r . . � . ' , .:,y.y' .. . .. . , . . . . . � - . . � � . . � . . . .�. � . . . �. � . � � , � � �� � � , ' . � . . � . � �... . . . . . .. . . . . , . . . � . . . . , . . ,. . "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 (336)751-8760. � OPERATION PERMIT , �j�f SYSTEM INSTALLED BY: �jI ''. l/'1 /%//�e'' � , . � � � r 1,�� �o��� X���` � �AUTHORIZATION 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 AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. � DCHD 0?J02(Revise� �i � � � t ( _ � . .. . , . _ , . . , .. . .,yr,. . � � . . , . � � .- � � � . . � - � � � �n:,�-� �f�.�� a ,, � - . . " • � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �- ' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME � �3 G� PHONE NUMBER �%� l��� / J ADDRESS �/� \ � � �� SUBDIVISION NAME - � 1 LOT # DIRECTIONS TO SITE ���� ��` ,/7"n�/d J`l� ! �l.Jyl �- ;� /p '-' 'Ci %�'� DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY � NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY CD SPECIFY PROBLEM OCCURRING � �`" L' DATE REC�UESTED ��`���5 INFORMATION TAKEN BY ���"G� This is to wrtify that ths information provid�d is correet to th�best ot my knowledg�,and that I understand I am rasponsible tor all charpea incurred from thia epplication. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 /! i,� � I S m;i�j �c��„ � � p��°" � .0 '�� '��� � h ��-�` c�".� `�,IaJ� .�'.` r`��� '� � � � �y��� � ��J�t � � - ; � � ��� `� � ��� .T �` ��` �� $ _ �� � � �'� ��� � �g� 4 ft� � �� � � �� � � _ � � � „�.`� �� � Q �� ��:� � �� �� r � �R.= y , �, � e �~ � � � .' ,r,:�, �, ''� � `� � � � � � - "F �N � � �`_.`�."_`�� [�� ,�'�. .�� ` :",�, �:;;. � I � � ,� � �, ; � ��m ,�G a�"`� :� �' �"� �°�� � .11 �t"l �.��`� � � , a . �s �, .. w, � 't ��` M �� �� � �" �„_ . , A � e_ ` �� � :.�,. __ � , � - ,,,. 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