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AUTX' O1ZIZATION NO: 17 2 5 DAVIE.QOUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's
P.O.Box 848
Name16.0 40=141fy Mocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760
Directions'to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
APt Zip: ��
Road Tame: lei-
*.*NOTE**This Authorizationfor 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 l 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
i! r' / ***NOTICE***.THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
„ `dh /r/ IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTALHEALTH SPECIALIST. DATE ISSUED
`�it�,��.,7. 1 £: � s �� �, at r'��`7 T ;t;.. 4 F�t+r/``,Com;* E. 1 - . �� �f ,•,.-. 3-- �7-,
^" VIE OUNTY HEALTH DEPARTMENT
7,25
-- IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
P rmitfeeV 1
Name: / ? Subdivision Name:
Directions to property: .�-r.+' fj�, �` '. 'a Section: Lot:
IMPROVEMENT
F PERMIT Tax Office PIN:#
3
Rd/ad`Nlla A IL:
Zip:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or,any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the,
construction/mstallation"of a system or the issuance of a building permit. ;
(Incompliance with Article I lof G.S.Chapter 130Aj Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,
i <c' y ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
01 Kt PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
r 'ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE'
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS�_#BATHS_ #OCCUPANTS l GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No "
LOT SIZE TYPE WATER SUPPLY-- DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH!'LINEAR FT..,LY .
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**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
SYSTEM INSTALLED BY;
•
AUTHORIZATION N0. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED W COMPLIANCE
UE=D
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALUIN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILYFOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised) ,
Job
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME ✓1 '1042P_,t PHONE NUMBER
ADDRESS ZZ 22 Q SUBDIVISION NAME
171acA!�-p'//,
_ 11-SUBDIVISION LOT#
DIRECTIONS TO SITE �� �9,EYn��
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER `
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY