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. aU�'H01�tIZAT1l�N�NO: `� � � '�ADAVIE COUNTY HEALTH DEPARTMENT �� �/�- �� " �
• - '- �• Environmental Health Section PROPERTY INFORMATION
Permittee's- /y � � ��� P.O. Box 848
Name: ���4�"`� ' '�'� � �e'�"` • Mocksville,NC 27028 Subdivision Name:
. " �. � . � ♦ i . . � .
i , ) Phone# 336-751-8760
"Directions to property: �� � �� +���7�= � Section: " Lot:
AUTHORIZATION FOR
� c�'` `�C'.;� E{'r` I , , WASTEWATER
� � , . �'� � � �� �� U ��� SYSTF,M CONSTRUCTION Tax Office PIN:# - -
��=�s , `
Road Name: t.lti���1_(`r,�.4 C r�Zip: '7 ,��:{..?
**NOTE**This Authonzation for Wastewater System Coastruction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.ThisForm/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with,�Article,l 1 f G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�" ,1 ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r.—r�� /�/����. � ``-� �`t D�. IS VALID FOR A PERIOD OF FIVE YEARS.
'-•ENVIRONM ALTH S ,ECIALIS'I'-''� DATE 1SSUED
. . , , . . . .
- . � F � . : , . .
N :�� _�. ' � '� ' _ �, � - , ��t ..� I� *> .
a x �•{� `� ;� �;; ���DAVIE COUNTY HEAT.TH DEPARTMENT r — `
;...-_ =;��� '� _ IMPROVE�VIENT AND OPERATION PERMITS PROPERTY INFORMATION
' � Permittee sh �^ " �
``��� �'Name:` � �� ��%'ti��� �'r� #'��r���``�"" � � � � Subdivision Name: ,
., i ,
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Directions,to property: "''�� � �v�':' "��,r ; �--'. Section: Lot:
` .. , t %' IMPROVEMENT
� � �'. . :i . '� �:.,, � ,• �...�i L. PERMIT Tax Office PIN:#
. a� .-.. ' Road Name: ;%',. ,a '', � ' Zip: �r . I
**NOTE**This Improvement Pemut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
, AUTHORIZAT'ION FOR WASTEWATER SYSTEM CONSTRUCT'ION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building pernut.
(In compliance with Article l l;nf G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
' . 1�`" - ! , j ***NOTTCE***THLS PERMIT LS SUBJECT TO REVOCATION IF STI'E.
' ��-•-�� '� � �`f;t,':- PLANS OR TI�INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMEN.TAL� E�ALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TIIIS PERNIIT BEFORE
;�. � INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE F I O f�k- #BEDROOMS�#BATHS � •S #OCCUPANTS�GARBAGE DISPOSAL:Yes "i No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No ,
/� r
LOT SIZE ' rI\��'TYPE WATER SUPPLY n �-�-�- DESIGN WASTEWATER FLOW(GPD)��U NEW SITE REPAIR SITE �
�^ � � ' � �� t
SYSTEM SPECIFICATIONS: TANK SIZE I vuO GAL. PUMP TANK GAL. TRENCH WIDTH `--�/ ROCK DEPTH � � LINEAR FT.�"�"-x�
OTHER i 1��S'IIL1��iO� b��
, REQUIRED SITE MODIFICATIONS/CONDITIONS: ��� �U 1 ��{. V`)�=LL, ���1 � C��� ��t7t�� � I l.l- ►rJ u rr�
,�-,�.
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IMPROVEMENTPERMTfLAYOUT.��t,,��] aUFA EFFLLI�E�T FILTEf:� '�I�IB:f:(S) I� 6�� ��L.Q;d FIP�IfiH'cI] GF�RI]i:��
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ij� � l oc�` ��G Y_��' ,a c�J �,�Lt, �.�,:�k.1
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION�F�'HI$�}'STEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS �04)y ��-�7�� . �
��ab)7:]�-876�
OPERATION PERMIT �n-`O'l 1^
SYSTEM INSTALLED BY: �t�v "[ ���, �L�=�
��� [1r��S �� ��l�.lL'y
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1 �'D X3(,`��l2"
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AUTHORIZATION NO. 1j °�I Q OPERATION PERM BY: DATE: � 0�
"`*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA H YSTEM DESCRIBED BOVE 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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96(Revised)
Y_ l� '� �- -- D �r ` � � � ��—•� U e�f� ��
` � ` ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION '',as-_ (oJ� X J i'j � M
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �
NAME �� � r� ��1 � � �l i f C PHONE NUMBER I� � .� I � �" y` �p
ADDRESS �� T SUBDIVISION NAME �
1� -� l � � � C� C� LOT # �
�
�� �
DIRECTIONS TO SITE ��o � � e x. ,L- /c�' / ( iC�� � J ° � �'� ���-- ,� E�
'� �'"' O r� asS ' �.a-,� c C'v� r�.�c-, (st��,•a� /�
DATE SYSTEM INSTALLED �SU �S NAME SYSTEM INSTALLED UNDER �
TYPE FACILITY NUMBER BEDROOMS �� NUMBER PEOPLE SERVED 7
�--�e _/J '�
TYPE WATER SUPPLY � SPECIFY PROBLEM OCCURRING v�— �- �
GL � c/( .�t_. � C- � � .� S � �„_ " �
n
DATE REQUESTED 3 v �� INFORMATION TAKEN BY �7� _ �• o
' � o
Thia ia to wrtify that the information provided is correct to the best of my knowle e,and that derstand I am res nsi fo all chaige n urred from this application. d`�
�
SIGNATURE OF OWNER OR AUTHORIZED AGENT � �.
Rev.i/93
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