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Permittee;s f �,,; ,, DAVIE COUNTY HEALTH DEPARTMENT
`Name: �'J�r�'� '-'r �t���'� Environmental Health Section PROPERTY INFORMATION
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Direc6ons to property: 1�4ocksville,NC 27028 Subdivision Name:
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Section: Lot:
��� �')��,ti 5 f Gr� L AU �1'A�STEWAT�ER�R
SYSTEM CONSTRUCTION Tax Office PIN:# - -
ALJTHORIZATION NO: ���� � � A Road Name:.��a�f �r.i Zip: � t`-'�'(�'
**NOT'E**T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Permits.This Forni/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
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l`..�,/ � ��' a' ����j --�—�— C ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.�°'lj�`���F'�."�,..�'ti�% �'I%� ����� t1 I IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DAT" E�SSUED
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RESIDENTIAL SPECIFICATION:BUILDING TYPE H #BEllROOMS � #BATHS I #OCCUPANTS�GARBAGE DISPOSAL:Yes or No'
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ��I� DESIGN WASTEWATER FLOW(GPD) Z�� NEW SITE REPAIR SITE �''—
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��f' ROCK DEPTH I Z LINEAR FT. ZV
OTHER l.�V� IAS-P �'��I Vl L�VY� SU�'T'(.�YYI. 2 � tC7
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT �h u n M G ����
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AUTHORIZATION NO.��s OPERATION PERMIT BY: DATE: 2 3 O
•'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TH YSTEM 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 FUNCTTON SATISFACTO$ILY FOR ANY GIVEN PERIOD OF TIME. ,
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,NarnF;•° Environmental Health Section � PROPERTY INFORMATION
, �4, � �.--�• ..- -
. �� P.O. Box 848
, . ; `'Directio�n to property: ' ' � ; -Mocksville,NC 27028 Subdivision Name:
•- � ��;.�<�" ,��?r i`) %�-;' ('-�►�;'?f J�;;�� � '�, Phone#:336-751-8760
' Section: Lot:
' - ,-,1.-� � � AUTHORIZATION FOR
``1 -f C;_�;� ;;� L,,1 � WASTEWATER Tax Of�ce PIN:#
. ,. SYSTF.M CONSTRUC�'ION - -
AUTHORIZATION NO: �Q��� � t� Road Name: �y'� (i / ��- Zip: %' L�'C3 l.
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� **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Pemiits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.�.;;':
(ln compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
,
r'f'`� , f',s'S ' � 't � ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
:-%'L��'l`�"is�'� ';�j�..�"±"!,' %'`� � `7 �'� � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE SSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE N #BEDROOMS_�#BATHS_�#OCCUPANTS�GARBAGE DISPOSAL:Yes o�No'
COMMERCIAL SPECIFICATION: FACILITY 7`YPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY �E�i I 1 DESIGN WASTEWATER FLOW(GPD) '�y V NEW SITE REPAIR SITE �''�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��,I ROCK DEPTH +Z-I� LINEAR FT.�„)ZV_
OTHER 1 ���'1 �i{�� ��!'1��1 �i�U1� S,�'�?�.�. � } v�C�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT "� �j
YSTEM INSTALLED BY: {J�G h M L I�1'�1 -
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GoMAPS -Davie County NC Public Access Page 1 of 1
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Davie County, NC - GIS/Mapping System
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