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152 Speaks Rd \.fiYt .�'�"_ t '.f S .T- r1: ` �:i� �:-�. i-5� h�+",._.r:f f7e��`-�f-`..v� ..�.:. i.� Y': .-. � ...'-• 1' �T..`�:�.,.t...v....:.. - , . - f •N-~� ��• y :. ;� J u-s fe,J �o�2,��-'�� ' 'Pen►Wiee's -� ' �� ' D VI CO NTY HEALTH DEPARTMENT ' '- .Name:--� �`.•�-` � `� '����:.�� _ ! '��vironmental Health Section PROPERTY INFORIVIATION ` -- �C� '1b. � ������ '� P.O. Box 848 "Dire�tions to property�.� ��- ��ih��={w Mocksville.NC 27028 Subdivision Name: / . � �� � .,� �1� � Phone#:336-751-8760 � Section: Lot: .. , � AUTHORIZATION FOR �� �,�."� �� .�-_ WASTEWATER Tax Office PIN:# _ , SYSTF.M CONSTRUC7'ION �y )� /'� ,,. AUTHORIZATION NO: � 1 ��� A . Road Naht��.� ``� �� ��Zip.�� � **NOTE**This Authorization for Wastewater System Consuuction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permit�.This Form/Authorization Number should be presented to the Davie County Building Inspections - Office when applyin�,for Building Permits. ` (ln compliance witt�Article i�1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). i;;/, , % l� '"—"�� p� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION' ,r� �';% �. ! �' , IS VALID FOR A PERIOD OF FIVE YEAR5. IR ENTk ALTH SPECIA SI' DA E 1 SUED �� � � '� �;' � ,.. RESIDENTIAL SPECIFICATION:BUI DING TYPE.��#BEDROOMS �"'�#BATHS�#G��S�GARBAGE DISPOSAL:.Ye r No � . COMMERCIAL SPECIFlCA'T�ON: FACILI7'Y TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE '�' �(�TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD)�-1 c � � NEW SITE � REPAIR SiTE �� ,� ` �� : ' _ SYSTEM SPECIFICATIONS: TANK SIZE� AL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH�� LINEAR Ff._.�A� - . OTHER S /.%��� ��QtJ�Zd� LiC/X� REQUIRED SI'TE ODIFICATI NS/ ND1TI0 : ` ' "�� A � d��� IMPROVEMENT ERM1T LA O � � � V� �- , -,� � � � — �-- � �O�5�: � � _ l , � � G ,� k�--...�-`�-' ,� . . . . . 1 . "� �^ � , � ' �� .. ' . G • � .��!'tn yJrcc- O_ t� , b' � �` �� ��t�'�al:t ;4-rn.1�wS N : a' �.s c.o.���2' . � ��. �;,..5�S � .�1�. : 'o 'a �� � ��S� t� 0�3"2 : v 12 �t,�=`�"� . � " ` ' •*CONTACT A REPRESENTATIVE OF THE AVIE COUNTY HEALTH DE ARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 830-9:30 A.M.OR 1:00- L•30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT t � � SYSTEM INSTALLED BY: r � _ : � �y s�" � � o� . � ��� . � � _ ; . . . A[JTHORIZATION NO.r/,/,C���PERATION PERMIT BY: C�'�'`�l DATE: �' ` ••THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WTfH ARTICLE I 1 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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 07/02(Revised) . , ' ��st� .. - , j,�c lv _ . - � • DAVIE COUNTY HEALTH DEPARTMENT D � � /� Environmental Health Section j L � � �' � PO Box 848/L10 Hospital Street �A�11 - Mocksville,NC 27028 _ 6 20�� s! �,�,.� � Phone: (336)751-8760 r " . ElVV/RON47ENrA�y�Ty. "; ON-SITE WASTEWATER CERTIFICATION FOR D ��iFr,a� JNIY �p. (Check One) REPLACEMENT❑ REMODELING ❑ RECONNECT ;; �' q�a�� ,� Name:�: ti..��L� ) u S i-t,�� Phone Number: `�(Home) t:; ��y Mailing Address: I.3 Z �v-e�-K-S �d . � `' (Work) � � n ' ' . . ' �-�-o� �ti c.-�. _ , : Detailed Directions To Site: 1 �--�' ti .�S e w � . L „����„I b.�J . l • � r�,�,��.� o� S -e L S�— a.�� o ,✓ � � �.�- �� Property Address: -�-¢-�S �°t' ' ;; . Please Fill In The Following Information About The Existing Dwelling. � ? Name System Installed Under: " Type Of Dwelling: L "',n,-�, {� Date System Installed(Month/Day/Yeaz): T�e��c�-d 4r� Number Of Bedrooms:3 Number Of People: :r Is The Dwelling Currently Vacant? Yes� No�1�Yes,For How Long? Any Known Problems?Yes� No mil�Yes,Explain: $� d �.�-�-� � o ;.� , . Please FiII In The Following Information About The New Dwelling. �I 6��� } Q� 1 `t- � '' Type Of Dwelling: I 1,� "`3-�- Number Of Bedrooms: Number Of People: Requested By: Date Requested: �/L /`a 3 (Signature) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ � Comments: l�l�'l ` I�l 4F. ���h., �T ( a �j j O l�t�"l�� �`� t�^-`. : . ' ;' Environmental Health Specialist r Date -3 '"�The signing of thi.s form by the Environmental Health Staff is in no way inten ,nor should be taken as a guazantee(extended or limited)that the on-site wastewater system will function properly for any given period of time. ' Payment: Cash❑ Check❑ Money Order❑ # Amount: $ Date: Paid By: Received By: Account #: � Invoice #: � , r 1. � . � . . . ' . . � . ' . . � . � � . � . . . . y � � / � . � � . . � APPI�CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& � � � � �I � , Davie County Health Department � , Environmenta/Hea/th Section ��� � P.o. sox 848/210 xospital street t JA�) - 6 2003 Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HfALTH ***II�ORTANT*** THIS APPLICATION CANNOT SE PROCESSED UNLESS ALL QUI`T2Eb=-J" INFOFit�TION IS PROVIDED. Refer to the INFOEt1�aTION BIJI�LETIN for instructions. 1. Name to be Billed \ � Contact Person c�-�PYI�, Mailinq Address Home Phone 1�y�0 'Qy�— c�0�� City/state/zZP �V������ Business Phone �T��e, 2. Name on Permit/ATC if Dif£erent than Above Mailiaq Aaaress cit3r/state/zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both a. system to service: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: g People �_ � Bedrooms L, # Bathrooms p2�l a �J,Dishxasher U Garbage Disposal �Washing Machine ❑ Basement/Plumbing �YBasement/No Pl�bing 6. If Susiness/Industsy/Other: Specify type # People # Sinks M Commodes � Sho�ers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �galions per day) 7. T�Pe of water supply: ❑ County/Ci.ty �Well ❑ Community e, .Do you anticipatc additions or expansions of the facility this system is intended to servc? �Yes ❑No If yes,what type? ' � � Q., C, � . ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the clieut with THIS APPLICATION. Property Dimensions: �. <)�(� QU��5 WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax OtTice PI1�1: #���(��-� ` ��- r� 1 �-. Property Address: Road Name � t� � — \r1 (lQ.S City/Zip 1 C�'�(�'��a�Ci�9 V`��1' (Srl ��� � If in a Subdivision provide information,as follows: l� M�i —r-- Name: � Section: Block: Lot: Date Property Flagged: �— � � �� T6is is to certify that the information provided is correct to the 6est of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information ` submitted in this application is falsified or changed I,also,understand that I am responsible fot al!charges i�rcurred from Jhis application. I,hereby,give consent to the Authorized Representative of the Dav'e County Health De�artment to eater upon above describcd property located in Davie County and owned by C�Ti 1� � �YY�� Cli,r �U.�'QSl to conduct all testing procedures as necessary to determine the site suitability. DATE lI�D I O� • SIGNATU . �— THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN nclude atl o the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): ���.� � Client Notification Date: \S G��«��,n�� o�""'" _ EHS• Y+��'_ � ��P c �Q��,�'(� Account No. �� �� �� `�.'`d ` c.� Revised DCHD(07/99) Invoice No. � � � .i- �5.� .V� . � '� � �,''� ' � F: � �.�Ms� ' �iY I �. �+"aNy� ' � . '�9 � i,�1 f�"� q $y. `�.`` vi!'� `� I}*�. � s�} f: . .r Jl=M ^�'� � '5� C�' 7 � �l� J 7M : r��r �w r�.a+r v'� . � ,i.' i �. 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