461 Powell Rd ' Pa?nxtee's/' J/ DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION �RROIZ
P.
Directions mproperty: ��h�. D�fP////dry ,xtocks�il �'JCa x7U?A Subdivision Nume U" �Oe�
r / l Ph<ne#'. 336-751-R760 &JrOA,
);///%� Section: I t/
AUTHORIZATION FOR '
WASTEWATERWASTEWATERTax Office PIN:# - - R.,pe7�,
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SYS'rEMEONSTRUCTION lJlCtbt
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AUTHORIZATION NO: 002599 adl Road Nome: Zip:
"NOTE"This Authorization fur Wastewater System Cm nlctinn MUST BE ISSUED by the Davie Countv Fm ror=Ins�pecfions
to issuence nLuny Building'Pemrits,'Ibis Pcinn/Authorizalion NumhcrshnulA be parented to mo'[)tviz Cotiapplying Ruildinit Permits. •o(In compliance with Article I I Of GS.Chapter 130A,Wastewater Systems.Section.190)Sewage Treatment and Disp
"NO"I]CF.*'s THIS AUTHORIZATIONFOR WASTEWATER CONSTRUCTION fli
L,/ys(w 7�•/ ``r ✓!T �'� ` IS VALID FOR A PERIOD OF FIVE YEARS. m
ENVIRONMENTAL`HEALTHSPEGIAI:IST ' DATEISSUED
14
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RESIDENTIALSPECIFICATION.,BUILDING TYPES #BEDROOMS pBATHS :2 #O(7CUPANTS�_GARBAGE DISPOSAL:Ycs or No n
COMMERCIAL SPECIFICATION: FACILITY TYPE'' pPEOPIEpPEOPLFJSHIFT #SEATS_ INDUSTRIAL WASTE:Yes or No (r
LOTSIZE TYPEWATERSUPPLYDESIGN WASTEWATERFLOW(GPD) 7�ONEWSITE REPAIR SITE 1 b
SYSTEM SPECIFICATIONS: TANK SIZE/�v/ GAL. P7PTANK_GAL. TRENCHWIDTH ROCK DEPfH,42 rLINEAR FTt�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS�L
c
IMPROVEMENT PERMIT LAYOUT
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ti
j6wa1I 4'd
FOR FINAL INSPECTION OF THIS SYSTIi.M PLEASE CALL,BUMF:EN 8:30-9J0AM.ON THE DAY OF INSTALIATION.TELEPHONE
OPERATION PERMIT
SYSTEM INSTALLED BY'
61d -f au A '41 . ) n
�S
AUTHORIZATION NO,aS�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 I'OFG.S.CHAPTER UOA,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS BUT SHALL IN NO WAY BE TAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN'PERIOD OF TIME.
Dean 0m2 ta...l—n Q. -7 SJ J 1 0 / 0
'Permittee s's-' DAVIE COUNTY HEALTH DEPARTMENT ��
,Name. �'~' ?60/a,�' Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 �
**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. 014
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(In compliance with Article i 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION M
-' _ �;' "�s "; IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISD _
RESIDENTIAL SPECIFICATION`:BUILDING TYPE #BEllRO0Iv1S" #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No (t;
.--1. � 7 f...:='
LOT SIZE TYPE WATER SUPPLY t DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE %`( GAL. -P13 P TANK GAL. TRENCH WIDTH ?/ 'ROCK DEPTH/(LINEAR FT.�l'�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS/ 6 � U,3r�
IMPROVEMENT PERMIT LAYOUT
�
j/ , ?
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
6 J
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AUTHORIZATION NO.rPERATION PERMIT BY: Z `- // DATE:�/�-1 S
**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 NOWAY BETAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOR`IILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02(Revised) J
' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATI'ON FOR IMPROVEMENT PERMIT(REPAIR)
NAME �G,(P� �XztIJ9J' ci' PHONE NUMBER
ADDRESSSUBDIVISION NAME
LOT # �i'�C
DIRECTIONS TO SITE /'
Al
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLEDer.�/>/1-Yl 04,4
TYPE FACILITY hl- NTO
BER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLYSPECIFY PROBLEM OCCURRINGry
/ e
DATE REQUESTED - INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge that I un sta d I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.V93 yj