868 Ralph Ratledge Rd - ,,. , r . . , . --u j r . ' - a,.: :v4,.�. '.,�-:" '=�� . - ". �:, , -
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DAVIE COUNTY HEALTH DEPARTMENT � �/��`�y �
N�e"` ( '���.�i-: �::t�i �' : Environmental Health Section PROPERTY INFORMATION
� � P.O. Box 848.
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Directions to property.` 1 '��� �� Mocksville,NC 27028 Subdivision Name:
' ' t~ Phone#: 336-751-8760
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�--a�.:�l%��i�`11a�J7 �"� �(� 1 ,�.:,,,,� Section: I.ot:
`_-�, r (�� - AUTHORIZATION FOR
� WASTEWATER
�1..1�� t'��`t L[:��t �: e �� t�.1�-� Tax Office PIN:# - _
SYSTEM CONSTRI.7CTION
AUTHORIZATION NO: ���� L,/-��� �"�1`l-.e�'C.z� �-'''� �
A ` Road Name: ? ip �-�. . ^sC'
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Perniits.This Form/Authorization Number should be presented to the Davie County Building Inspections'
Office when applying for Building Permits.'
(ln compliance with Artide 11 of�.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) .
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' � ,l'' � �n`�.:, � ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
' M+'�'� - G�', ' � t,� U�. ` IS VALID FOR A PERIOD OF FIVE YEARS. '
EN1�tItONME AL;HE . 'SPECIALIST�DATE SUEO :
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RESIDEIV'fIAL SPECIFICATION:BUILDING TYPE�w-�#BEllROOMS.�#BATHS � #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ��'�' DESIGN WASTEWATER FLOW(GPD) �� NEW SITE REPAIR SITE '�`
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH 1� LINEAR FT. ��
OTHER � ~lJI�`jT1�.1�v�IUt,! �'Y�� :
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.�; REQUIRED SITE MODIFICATIONS/CONDITIONS: �'""���-O� C'��J'��� t`i'`'� ��t� ��Y�lj'��l �"�"`�" '�� "i f==yp1�^., {,.�t.�L •
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IMPROVEMENT PERMIT LAYOUT
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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 (336)751-8760. '
OPERATION PERMIT ; I �lL.b�1T
SYSTEM INSTALLED BY: �L-L-��-`�
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AUTHORIZATION NO. 'v�lY<'�OPERATION PERMIT BY: ATE: !/3 I
*'TFIE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS B INSTALLED IN COMPLIANCE
WTfH 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 Tf�SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. '
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�APPLICATION�FOR IMPROVEMENT PERMIT(REPAIR) ������Zf
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NAME " � � '� _ PHONE NUMBER ��D
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' ADDRESS �(�� �kl���-- IG���7uf � S�UBDIVISION NAME
��JIcS LOT#
DIRECTIONS TO SITE
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DATE SYSTEM INSTALLED NAME SYSTEM INSTA ED UNDER
TYPE FACILITY NUMBER BEDROOMS -3 � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY W�i�V SPECIFY PROBLEM OCCURRING
DATE REQUESTED � lU INFORMATION TAKEN BY
Thia is to certity that the iniormation provided is corcect to the best of my knowledge,and that I understand I am responaible for ail charges incurced from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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Rev.1�93 - �
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