1275 Rainbow Rd AUTHORIZATION NO: � �� ��'DAVIE COUNTY HEALTH DEPARTMENT
�@ Environmental Health Section PROPERTY INFORMATION
Permittee's f � � � P.O.Box 848
Name: ,� � L ,,, Mocksville,NC 27028 Subdivision Name: �
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Directions to property: i'��; /Cw' Section: Lot:
� AUTHORIZATION FOR
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� f'� SYSTEM CONSTRUCI'ION
Road Name: Zip:
**NOTE**This Authorization for Wastewater System Conswction MUST BE ISSCJED by the Davie Counry Environmental Health Section prior.
to issuance of any Building Pertnitc.This Fortn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage"freatment and Disposal Systems)
���� �/ ,�/ }� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�"`�f,'l� ' I� ;�G�;�'Il � �. l�1 �%i IS VALID FOR A PERIOD OF FIVE YEARS.
� ENV[ ONMENTAL HEALTH SPECIAUST DATE ISSUED
RESIDENTIAL SPECIFTCATION:BUILDING 1'YPE_� #BEDROOMS #BATHS #OCCUPANTS�_GARBAGE DISPOSAG Yes or No
COMMERCIAL SPECIFICATION:FACILIT'Y 1'YPE p PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAI.WAS7E:Yes or No
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LOT SiZE TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD) NEW S17'E � REPAIR STTE ��
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SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�ROCK DEPTH_�;LINEAR Ff.�'�/�"�i�
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REQUIRED SITE MODIFICATIONS/CONDITTONS: �
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IMPROVEMENTPERMITLAYOVf#APAROVED EFFLUENT FILTER* *RISER(5) IF 6" BELONI FINISH..D 6RHDEt
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••CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BEl'WEEN 8:30-930 A.M.OR I:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS�2{4'�E���6ti0x '
(336)751—&760 �
OPERATION PERMIT ,
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. OPERAT[ON PERMTT BY: DATE: ;
"'�TF�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE �
W1TH ARTTCLE 11 OF G.S.CHAPfER 130A,SEGTION.1900"SEWAGE TREA7MENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACI'ORILY FOR ANY GNEN PERIOD OF TIME. �
DCHD OS/96(Aevised) � '
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� AUTHOF.IZATION NO: � �� ��`DAVIE COUNTY HEALTH DEPARTMENT � �
� Environmental Health Section PROPERTY INFORMATION
Permittee's , un� P.O.Box 848
Name: � � C ,,. Mocksville,NC 27028 Subdivision Name: •
!/, Phone# 336-751-8760
Directions to property:�� 7 S bf;���; �d K. Section: Lot:
� AUTHORIZATION FOR
� %:!{ :�r����, , �y / �-�,�,/� ,� WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
Road Name: Zip:
**NOTE**This Authorization for Wastewater System Conswction MUST BE ISSCJED by the Davie County Environmental Health Section prior.
to issuance of any Building Pertnitc.7'his Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pertnits.
(In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�,� ' ` ' "*'�NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION
j"�( � ';��,(�L%�� ��"' `i IS VALID FOR A PERIOD OF FIVE YEARS.
� ENVI ONMENTAL HEALTH SPECIA IST DATE ISSUED
RESIDEN7'IAL SPECIFICATION:BUILDING T'YPE�_ #BEDROOMS 71 BATHS #OCCUPAN'iS�GARBAGE DISPOSAL:Yes or No I
COMMERCIAL SPECIFICATION:FACII.ITY TYPE #PEOPLE #PEOPLFJSHIFf #SEATS INDUSTRIAL WASTE:Yes or No ;
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LAT SIZE TYPE WATER SUPPLY�� DESIGN WASTEWATER FLOW(GPD) NEW S1TE REPAIIt S1TE ✓ " �
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SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�l ROCK DEP'fH�LINEAR FI'.�� .��
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REQUIRED SI7'E MODIFICATTONS/CONDI770N5: 'r j
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IMPROVEMENTPERMITLAYOUT#APPROVED EFFLUEN7 FILTER� #RI&ERtS) IF 6�� HELON FINIS!-tED GRRDE+� �
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"•CONTACf A REPRESENTAT[VE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECfION OF THIS SYSTEM !
BETWEEN 8:30-9:30 A.M.OR 1:00•130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS��1�{E�3`���Iat`!x •
i336I751-8760
OPERAT[ON PERMIT .
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. OPERATION PERMIT BY: DATE: i
*•THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT Tf�SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPIER 130A,SECfION.1900"SEWAGE 7'REATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY HE TAKEN AS A
GUARANTEE THAT T7�SYSTEM WII.L flJNGTION SAITSFACTORII.Y FOR ANY GNEN PERIOD OF TQv1E.
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; ;AUTHORIZATION NO �`� +�` ���''DAVIE COUNTY HEALTH DEPARTMENT
� _ ' ' Environmental Health Section PROPERTY INFORMATION
Permittee's- - ' � { ` P.O:�Box 848
Namei� �/ L� Mocksville,NC 27028 Subdivision Name: �
yf� -/ Phone# 336-751-8760
- -birections to property:Iot 7���"���. r�w; N:. Section: Lof:
- ��' : , j ' j/ / AUTHORIZATION FOR
� �' / ' r,• WASTEWATER
� />,�'.�• :x�fl�//.;.� /' rf ,rt 9'/� /,� r�' Tax Office PIN:# _ _
, - SYSTEM CONSTRUCTION
r . Road Name: Zip:.;`
**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.'fhis Fomi/Authorization Number should be presented to the Davie County Building Inspections
` `. Office when applying for Building Permits. :: ,
(In compliance with Article l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
: . ,... , f , . . , ,: : , �. , ,,
� �' ,� ,r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f " � ��.-� f,�4'" . . f f `'' . ' ' IS VALID FOR A PERIOD OF FIVE YEARS: ,
` ENVI ONMENTAL HEALTH SPECIALIST ,' DATE ISSUED ,
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��,�.�_ ,�---- , ;- TMPROVEMENT AND OPERATION PERMITS PROPERTY-INFORMATION .,
�Peifu�tee's:�� � f f�'} .
Nam�: �'��.f x4fl�'��.��' lt,rn �r „;;�" ' 5ubdivisionName:
��Directioi�s to property:�x«.� t7 ��'ti`, '� �'�: .�� e Section: L`ot:
' `� ' ,r IlVIPROVEMENT
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,- ,; � ���� ,r,�r r� .f i� :t' ,-�,PERNIIT Tax Office PIN:# _ _
. Road Name� Zip:.
�, - **NOTE**This Improvement Pemut 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 thisDepartment'prior to the '
construction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S.Chaptei 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � '
' `' ***NOTICE***TI�IIS PERMIT IS SUBJECT TO REVOCATION IF SIT'E
,� " .��' , a � � �'✓ ! .�`',f ,�' ,�',r `...PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER. ',
ENVIRONMENTAL HEALTH�PECIALIST' DATE ISSUED �` SYSTEM CONTRACTOR MUST SEE THLS PERMIT BEFORE�.
, '': , , - . , r ' `. . . , , _. SYSTEM.-.
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INSTALLING THE ' •
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RESIDENTIAL SPECIFICATION:BUILDING TYPE�y #BEDROOMS��#BATHS_�#OCCUPANTS�_GARBAGE DISPOSAL.Yes or No
<COMMERCIAL SPECIFICATION: FACILTTY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WAS1'E:Yes otNo ,
�`, ', . .. , .. . ; ' ' , , :, ,,, ;` ��,�
`LOT SIZE TYPE WATER SUPPLY.�',�/r// DESIGN WASTEWATER FLOW(GPD) NEW SITE- ' REPAIR SITE
_ � �� ;,
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTf3�(� ROCK DEPTH 1� LINEAR FT.,��r ;
- OTHER �'
REQUIRED SITE MODIFICATIONS/CONDITIONS:
.
,:
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IMPROVEMENTPERMITLAYOUT�F�p�OVED EFFLUENT FILTER� �RISER�S� IF &�� BEL.C9l�i FINISHED GRRDE� , . ,
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**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(�i�f�NB�
(33&I751-87fs�
;OPERATION PERMTT
' SYSTEM INSTALLED BY:
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AUTEiORIZATION N0. 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.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII..L FUNCITON SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. .
DCHD OS/96(Revised)
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, � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
' � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 1�
NAME !1 �/�ei � PHONE NUMBER "
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ADDRESS S W UC/� SUBDIVISION NAME (�
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LOT #
DIRECTIONS TO SITE �
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DATE SYSTEM INSTALLED � NAME SYSTEM INSTALLED UNDER
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TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING A
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DATE REQUESTED INFORMATION TAKEN BY o
This is to certify that�e iniormation provided is corcect to the best of my knowledge,and that I understand I am responaible}or all charges incuned from this application. � �
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SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1�93