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190 Milling Rdf a vi a ..! .,, 'i ..-*y? 4^e .41:s e:f.ti-..-0v!,j "y •''_1sv as"ry ;� �,.. ,f r-,(}/,.' ,( Fy .: ..., t At , I i,91;UZ-ATION NO: (, }' DAVIE COUNTY HEALTH DEPARTMENT _ V ° Environmental Health Section PROPERTX INFORMATION Permittee's,�) P.O. Box 848 Name: /- `i� '1 ��-� �-i- Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 Directions to property: �`�'���'^� t"`"C" � �% Section: Lo[: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION OuV, �'jlCC1�.1Cy ,..r C"' Road Name: Zip: **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,w•i--:0e44 of/(3.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRO EN AL LTFI SPEC1,KlS DA ISSU D W "DA COUNTY �� HEALTH DEPARTMENT �» IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee's 'Name: i i `'I -_- i + ' Subdivision Name: Directions to property: 1`' �� ` c; Section: Lot: IMPROVEMENT h.aR: (L L t r PERMIT Tax Office PIN:# ~- Road Name: / t C L j c, Zip: r **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 constructionfinstallation of a system or the issuance of a building permit. (In compliance with"Article..I 1 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 DA'lt ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE t INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE )U &# BEDROOMS # BATHS ,2' 5- # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY TY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE _ , F —7 11 1 SYSTEM SPECIFICATIONS: TANK SIZE ` GAL. PUMP TANK GAL. TRENCH WIDTH `� ROCK DEPTH �`- LINEAR FT. J �� REQUIRED SITE MODIFICATIONS/CONDITIONS: INi IMPROVEMENT PERMITLAYOURAAPPROVED EFFLUE—EW FILTER*,�t�IEf'dSj'' IF 611 BELOI1 171HISHED GRADE* � y r!� (C p ,r s, QZ "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�(9tP4j63A=g7btf. (336)751-8760 OPERATION PERMIT SYS INSTALLED BY: I1� a i4k L. c-1, 3cs F-`. ,> 1,j Deckc-4,1 j��• SV�Ct2 W 4iv'Y1- �►��c�J Not- cv� i AUTHORIZATION NO. OPERATION PERMIT BY: DATE: % 142 "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS RIBED A V 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) DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION 0 -71Z---M? APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) 0, 741, 3%?j- NAME ArjoI &-OAj PHONE NUMBER 0 i6-1'�Z�'� µ ADDRESS "`© MALUOJO �, , Me -y-,3 VtLu� SUBDIVISION NAME -7Z7 Z LOT # a DIRECTIONS TO SITE r DATE SYSTEM INSTALLED NAME SY TYPE FACILITY �OL)�C NUMBER BEDROO TYPE WATER SUPPLY----CSPECI DATE REQUESTED 1 I23 W - J STEM INSTA ED UNDER MS NUMBER PEOPLE SERVED FY PROBLEM OCCURRING `Jrt��- i�C� LW FORMATION TAKEN BY Cl 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. 1/93 QJVAD 3 `ice ko Wd c N'( C15N