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1852 Underpass Rd � . � DAVIE COUNTY ENVIRONMENTAL H�ALTH P.O.Box 848/210 Hospital Sh�eet Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990004491 Tax PIN/EH#: 5871-77-8297 Billed To: J. Christine Dean Subdivision Info: Reference Name: Location/Address: 1852 Underpass Road-27006. Proposed Faality: Residence Property Size: ATC Number. `�809 A **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. SystemType:�(��S.T.Manufacturer��%+ Tank Date ' �� fl�TankSize�� Pump Tank Size �J � / System Installed By:l-����-"" �L' ' �.H�'. Sp i list. e: ) 21, ��j I � ������ � �����Z � _� � ' �.� , ., � � � � � � � � 3�� � c� � ���� � � �� • ! � � 7 1 � ! � ..l �� �! -�� � �� . pCHD 11/06(Revised) � 3�� �• ~' DAVIE COUNTY ENVIRONMENTAL HEALTH Q�, P.O.Boa 848/210 Hospital Street 1 tQ1 Mocksville,NC 27028 �` (336)751-8760 Fax#(336)751-8786 `ti� AUTHORTZATION FOR WASTE�VATER SYSTEM CONSTRUCTION Account #: 990004491 Tax PIII�Yr�HI� 5871-77-8297 Billed To: J.Christine Dean , Subdi'moi��rtn Ihrl� Reference Name: Locatc�mJ/� 1852 Underpass Road-27006 Proposed Facility: Residence Pr�rl�r�'� ATC Number. 2809 A Site Type:�w�Repair ❑Expansion �� **NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section.1900 Sewage Treahnent and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential5pecifications: #Bedrooms�#Bathrooms 3 #People� Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size, � 5 �� Type of Water Supply:�ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) ��Tank Size rl.�z.t..i GAL.Pump Tank GAL. �� .. �� � ( Trench Width � Max.Trench Depth�(�T Rock Depth_� Linear Ft.�� Site Modifications/Conditions/ er: Ir.���L\,LL.. ,N� � �—� S1 �� �v11-D1'�L7 Co ct the Davie Co t Environmental th Section for final inspection of this system between :30—9:30a.m.on a of insta tion. Tele hone# 336 751-8760. � ti �1�� \ � �'� � � l:_1�S�l�JC.� 1 � � � \ � F�f�l?5�. � � � c�` � 1 v��- � /•, � � � � � _ ��y"f . SL�.�1� , P�� �� ���5 , � i , , �, �' ��__� � � �� � ��S�I � � � R� \ J � ���.- —�fL�� �� �i,�0 J�6Li.. � t?�� � C,'3"�1� ,+�r As $iLted ln 15A NCAC 1t3A.i9� S) �cc�pted Systems rriay �Iso bc� u&-d P�°�� , L`D�1��--� � t� K'�,�� 1�'lZ`` � �-�_O� _ , D Environmental Health Specialist Date: �����i.�� , � DCHD 11/06(Revised) � . , ' � � � .. - . ���� �` . . . . .. ... . .. � . . . . .. . . - � ���� � .I ... Permitt��'s � ' a +' '" � DAVI COUNTY HEALTH DEPARTMENT �� �� � � " Nafne� �`''-`' ' ' `��' � '��`�`��_.�'�s:v�"'' Environmental Health Section PROPERTY INFORMATION r'j,�d � ;:� � _ ,,•�, P.O. Box 848 Directions to property: f- •�--�� � �� Mocksville, NC 27028 Subdivision Name: � � � �^- �� p" `�C Phone#:336-751-8760 , �, �,fn.�`.�..:i tii'"�' _� �.:.� . Section: Lot: AUTHORI7,ATION FOK _� ��2�7 WASTEWATER Tax Office PIN:#'Ud»i SYSTF,M CONSTRUCTION . ,_. � ; �.. AUTHORIZATION NO: fl���%�� 1� Road Name f' .'� -• . .` ���Z�p.' � _k_.f�� **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authonzation Number should be presented to the Davie County Building Inspections Office when applying forBuiT`dtr�Pennits. (In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ' { ( r .�(: � : ,/�)ti �„�' + ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION � ` , (�`""-./ -i,c.�,��. ��.. I`j �i.,? IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONIvIENTA�HEA[�I'H SPECIALIST DATE(SS��ED - _,4..--. _ ! r RESIDENTIAL SPECIFICATION:BUILDING TYPE 'i: �� #BEDROOMS � #BATHS t-�` #OCCUPANTS�—`�' GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No (, )�{,f'�„'�� {'�,� f � i..�'. � � LOT SIZE �TYPE WATER SUPPLY""""'����DESIGN WASTEWATER FLOW(GPD) �4�--�---� NEW SITE REPAIR SITE ..._, r� ^ ,� r.�._�'J, SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH����''" ROCK DEPTH� LWEAR Ff. �=�, OTHER �n)�fi�.i..�. �,�1�� C.,.�--�`tv J G:; ��i�y 1:.�' ��.- �� �^ f � REQUIRED SITE MODIFICATIONS/CONDITIONS: `' F""��-�� �f� ��{C-'✓�:.� �-�� ��.., . __.._.__ _. ._ � s-,i_.`�,ti''� it'.L4- ��_..,� IMPROVEMENT PE�iMIT LAYOUT ��j�_^ �,! 1.;►Cl� .'>J�tik r-._C� ���!r%: - �``''"--__._.--�" a;•; ] -._/' ���_.._____—�—_� � /`\ C�.��J�`I��c:�ii��1 � �. '________._~\�' \ , ,�'��`'`�� ����-1.. � _ r-� � � � �f:l.,��:� r�.:. �1�� ,.a � �+_� .��('�l�, �\�i_-���r.M1�� :F:`��,�;� �,�r��'_�� — f-(L,t.i'w�=- --____ \ i 1.-L�el;.� �t��;l`�1'}N�� � � /� ,� � �,f. �? I t����„i C�„�.! � _ `.�....-.z � ,, �.. __. (r:�f vs�:a.,.�.._ ., , . --�•,.�.-.-,,____ ,_,,:---� , �,iC�.F L�;,F- '""r,,. , ,� �,_�---��� ,C'C1�=:M'� J' , ..r-�' f �,i:.�-:�-r�u,•t � � !i' ��,:1 `-�i�trJ L-� f � ` 1 �� t. ,, ` �r.l:..� �,,/ �-"^'.w�...�?i,�S���?.��t-�` '�' �'� ,./ "���'',�=i � ^� -�" , � � �- � _ , j `J .---�...-- �``-.--... • G.r:�;�T'=�C-1�i�i� �{��i C..� �� s ���,_`-�-,�; � ,Z " _-..__- (�.:�'c;'�> F�=�� ; ,��V_.___.___,_ __ .._ . � �, :, �. � __ �,�,a ,�� ��yt��:. �ic� �=Ja;:,C;1ItJ�J1�,1(� ` �r t�.;�l:� _._.._..._. r�__ _ �.-��....%t�c'��k=-�.-7�t7�.� c.`�� -`"�-`(�=7'h. s —__.---- _.. r r 6"�s Lt�i�c! in '�5� i���1C: �i?�,.19rs(�� �. �ccrpt�d Sy�tc;ms ���ay also b� usva �� FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT _ — —_ SYSTEM INSTALLED BY: ` � � � � �.� �v << �, � � �� � � � , �� ,v. _ �'l�`�_-- AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "`THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WTI'H 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 02/02(Revised) "� __�� �r'�(/,/'j ' ��.�v� .�"•"� �.� �°ixz� .n-� r.r.�'--(_,� �.�r,,�={ ..,: � .._, ,r � ' ' ,- .va.. �r —,r x 4 ?-`� d-�';v,-t,g. e.:.,. ' r�.v�'' s �.,,. �-a;; ! ��a,., .- , le a � - � : ��r � �, � . � .. , ..F . '. .x ` � r r, ...`. ,- ' .. 4. _ _ I "'�.3 Permitze s � �'� �`� ' � DAVI °COUNTY HEALT,H DEPARTIVIENT ' ���' .`. �, u. ���� ._� c� �'NaSne�` ' �'�' � "'� � � �' 4' Environmenlal.Health Sect'ion ° " PROPERTY'INFORMATION d -. : }, ; . -. �. ' ;tt� � .: � ° � P.O: Box 84`8 .. �}�t� .` ._ . � � _ � ` ._ < II , � . .,� � , y' . , .` ro ert �: . �,. " .. . �� ' 'Subdiv�s�on:Name -,, } y -' � '. 28� ;: Direcuons top p y ` � Mocksv�lle NG�7� � ��� =1� E � � ��"'�� �� " - Phone#: 336 75r1 876+0- . - ' ' ' ;f Sec,tion� �Lot: _ ` � �� AUTHORIZATION FOR ' z �' � '� — �� ,t,- WASTEWATER, "� � ,,a . :���-�_`-�2�r`7 Tax Oftice PIN:# • ' ° " . SYSTFM CONSTRUCTION � �. ��, �� ' �� �,�i h����,,� �� _ x AUTHORIZATION"NO �������_��: A - - � Road Naine. ��.�'��' Zip. �� �.� �� �; , ' ,.: . ` " . �; . D `S Stem Construct►on MUST BE ISS�ED b the Davie Countv Env�ron � _ � �� **NOTE**'I'his Autlionzation'for Wastewater y � � y mental Health Sechon;priqr : � ` d to'issuance ot any�Buildin�rnute��This F�im/Authonzation Numher'should be pcesented to,the Dav�e Gounty Building Inspections ' � Of_fice when appl.ying for�uilcfit��Penn�ts.... . � , � ; , ` _ � � :{ln compl�ayn�ce'-withiArCicl,{e 11=of G S :Chapter�!130A,Waste�vate`r System� Section.1900 Sewage Treatnient and Disp��sal System�) - ,� r '�" ::•_lt��' � 3' . �f .� -;�� ... . . � � � .. � � . ..- - . . ; ,� �"' � � ,+` :.�, �;� '`� �. ***NOTICE***THIS'AUTHORI7.ATION FOR WASTEWATBR,CONSTRUCTION' '" �� G� ° - IS�VALID FOR A PERIOD OF FIVE:YEARS. . �� � ? ,`s.��'��r'"'s��r� .�..z £ --�`� s , �ENV[RONMEN�`�EAL#�T�H SPEC�IALIS,T -_ D�TE,ISSI�ED , - . _ . ,;� y i'�,- ,', . �� r : . .;, . , ` ^ �. ' , ,� . � � , . . �J „ . >RE3IDENTIAL SPECIFICATION BUILDING TYPE.�#BEDROOMS / #BATHS � , #OCGUPANTS� �Y.GARBAGE DISPOSAL Yes oi.No .� � . • �� � . �- ' � . -� � 'I'_ l, . . . � � . ' .� .' ' �'_. • � •COMMERCIAL SPECIFICATION FACILITY TYPE�� #"PEOPLE ` #PEOPLE%S�IIFT #,SEATS _" 'INDUSTRIAL WASTE Yes or No T� �; ,., 1.� ,���� -- �',;� , { �� -,; . . ; a ;� ' � ��` , , �ir LOT SIZE � �� TYPE WATER'SUPPLY`��'!�DESIGN.WASTEWATER;FLOW(GPD) �e�.� NEW SITE_ REPAIR SITE �`d - .� a ;, ,° . ! �., � :, `" � ���_ ,. � , s " � , - '^��' e t �y';' a .� _ 'SYSTEM'SPECIFICATIONS TANK SIZE '� GA.L �PUIvtP TANK GAL., TRENCH WIDTH�?' ` ROGK DEPTH� LINEAR Ff.G� `� L OTHER *,�� ` ` !r. _. A � . Y �' �9 r - -� � k � .. .. '. , ; . ' .. .... � � '. _ .. � . _. 1�°fi�:�.��� r:��� q� 6� � ��+ �- ` � ��� � �,� . .��: � � REQUIRED SITE;MODIFICATIONS/CONDITIONS ' � .�,,,�:.�-�'^'.-�•;�. .^-'a'3 . f , - �� ` , , _ _ , -"""il-�"_""-�,.: ' . , 1f � " ��,� ��; IMPROYEMENT PERMIT LAYOUT ! �``�,�a ` � „ - � � �. t : .� �� p r� ^ ,, �.-•..-:...^","^ . , . , �e. . . ����� .�;� ���� :� �.� � � � � � � . > ,� �. `�.:�� �i, � ��"""���_ � �� . � � - ` - � , a � ,. � �� , ���� � � _ � ��. �� . ��.,.��� zi� � � t; � , . � ���� ����t �. - � ��`. � �� • -d.� �_/� . .. . � _ . �� . . . �� -� ���'�'` �4-lt�t�� � - ' � a ��-. � �C.������tc�1 � . ,� 't - . �� � �""_""" ' ' °' � � , � ` � � � ! ��'��67 '��+� - ` ` - .� � �`��t���� " ` , � ' -,��.�� .—w...,.�*�" � w,� �,�� ��-f , - ` r . . �' � �.i��.�fi��:' � '�� �/ "� �! ��^�� . . � �., . . • . _ .. � , ,_ �_ , . �. �� , r , . , , _ ,. _ , , . . , �.:R � r - r � -� !�"�,�--'I�." , - . . , � �s � ��'`��r:��c��`� :�.., �� . � � . � -�� . .� ,� .� . t . . r , : �f� ` ' ��^+44,�1 '�l� !�.._ � �t���, r�rK.��.��..-�----'?� ��z.4A't�..�� {�� , � � `,�-� � 1 J � I F- ���� � LL � �'�, .. � �. ���^uML'�� . �_ .. .- . � . . _ , _ _ T ` ��a�..�� .����t3 �.:.._�..::� �: � ° � �. �! , � D �.. d -.. . . � . . _: 3 � �. � � . . . ..," . . ` ,.. �jn)�"1"�'.L�.��� c� �� � - L �� , , . �. - 4 . � _ � � .. . n As st�teci in 15A"I��:AC 1�A.t98�($� � - ' :�ccepted Sy�ts:ms �iay also b� use "y s': 'h'�� . � � � ,� . � , . . � �, _,.. ,- , „ . , , . e.,�, .. , . . . . � , , , � . � - o��' : .: _ .� , _r, � ; � _ v ._ � ,. — , .11, . if . . . -: ` FOR FINAL INSPECTIONAF THIS SYSTEM PLEASE CALL BETWEEN 830-930 A:M._ONijTHE DAY OF INSTADLATION:TELEP.HONE#IS(336)751-8760 _ I � ';OPERATION PERMIT - -� �, , . �f '' ' ."t��.,� - - ' " SYSTEM INSTALLED BY ��� �'�� '�-�''�.." �,��'�� ���'``� a�'����' `�� �� �s ,�, }�. . , � �.r' e�. �ae",�+�r��r�°�"�'�.�'�'h�-°,�u � F`� ��o� F x,_, r � ., r� � �r� � °$''�`i.�,n`����� ��, ����� .�` �'� ����� �� � �. i � _ ,�, '- ,�_ � " k �� � z��`fa£� �n� 'Y �e y,�� ��3 ,�" '.a� 3 � ��, . . . ' . 'r . 7E� .������� � .:3,�"�` �,�i3.�LK.�rc `f,�'� �����/ �'�+4 il, .. ' . . + . '�..�� i;a..i � '''*�.y�,��`y',�y.i3 � ��t� 6 . - . '�s Ys ' "'i, so .4�' r^. � �g ,E !� � I ' , _ ' , J� - a;k F�� ..-�!���,�`E ° a�. �s�"'� r�-=4�' ��'��`"�� ��,r ,. I-�'�•' . . . ,. � .. � ��.o'�-�� � �, .a.-�'�'��'��� .t��'+,.;1� �� e.� . � �. . ' ��.'�''� �� a'bM` �-�� < �\ ��,,,� ry� �4� - ' u�� � s � . y, }��s�'�>.��r4����� i ����� ��� ,R^ ` � r'� '��`�"'� �� � � r,'i � , ' � 'i �k`�.. 4 ����54�g� h '�` �'.'� � "��`� bF'1'��f° f��'=� i' 'i, y��. ��a z� �°�d ��.�� r �Y � f'_ - . � , .. 1 � z ,,� �,s�� k�`���� �'.:'f��r �t �� � � �. �.� - � - i - r �t �' SA�� re�, p �, ,r^r��c{ -{,� c a �,� , ` � , �r". . . , .. . • .. ^�'' �x3'�`� ��`` �"� �� �:� �•Pa��'w`,�� �e �,� � .� . � , �e , � F �� & ����4�� � s. a ". e,- ..,' .� � � `. - � 'i 'i F �5 ^5 � � t . ra*������a `�,�e"�a c� � 'A "����»i����;i� �,.� � �"'��,�, i �, � . , , n, .,� �aar����"a.3is�7�'�� ��. .��� ���.-'��''�'"'��d'�''� '� ��5.�� �1�"�.�'�' , .°} . : , .� . Ryg. Po : ' u y . . . e... . ..� t� '0 �,e'3 . _ , a-9�����,��1�£��'� �c��o_'-�k'�'�' �`A.����Y�m �� �. 6 als. 1: , .. � �. � E4 �ty�" � � ti�� �Y S .w' L _ �.� �. _ °v,,. , . ' : `�.,. "iF, !� �,������.�-���,��,���� �i�'���'�s� ��3�0��� � � �� � � ��4� ����� . .,� _ � , -� � '�� �: ,� ,� � � -t� � 4 �� � 6� �` ���� �� �� '�b^ � ��, . - � . - " " �.�x„k. g`i^����.� /['�,,.�^�w�`��,�,�+.Fr�r-" �s-dr �` 4 . �, - . -V� �� �� .x t £^ .x�i9f6�r�.F d'�.p�k�tb���+''��yu6� ��;��x�,� � �� ��' �4� , ° �` ,Ly r, �,� '�-3,,';d-+';��,�A'k������$�n�4 rv��� �����:�'��� z �ti , r w sa�'��# a� �� � . t � b ' - ; -'��P' x�� ���k�'} L��1'ti'�� �¢:,�i NJ� 'r. �a _ d� . ' _ . . G r�t � kr��,' P aq ° � Y� �d s� a�'� �� ,, ,. , , . . # � , . • � , �� ,,_ �.. , ., • { � � •. ' �1,� �i �� � r � y. .� ..' a � . :.. � �__ . ; . .�°iL . �'�z' �' ��� �-E:r��°�.=�_v �'� ?::.'.. � ��`... � '�s}«$d � i a`. e � `. � , =AUTHORIZATION NO � '�. OPERATION PERMIT BY � DATH TH&ISSUANCE�OF THIS OPERATION PERIvIIT��HALL INDICATE THAT THE SYSTEM�ESCRIBED ABOVE HAS.BEEN INST ' �� ;++' � ALLEDIN COMPLIANCE�' � � ,,•, WITH ARTICLE 31_OF G:S.CHAP'FER,+130A,,SECTION.1900"SEV✓AGE TREATMENT,AND DISPOSAL�SYSTEIvIS"„BUT SHALL IN,NO'WAY�,BE TAKEN AS A , ;GUARANTEE THAT THE SYSTEM WILL�FUNCTION SATISFACTORILY FOR:ANY GIVEN�➢PERIOD OF TIME. . � , - . e _., . .� � � . - x , :,,_ :: � � � .. _ _ � eDCHD`07J02(Revis�) � .. . _ i 4 , 'I ' ` _ �y . , _ �ii1����;� : - � . . . __ _ .. . . �f ��� � _ _ , � . �; - Permittee's �, • � DAVI� COUNTY HEALTH DEPARTMENT '��� ^ ,�_�,; ""NafneM �� '�'/` �'" � �i �`'��a• ._p' � .��1°;''�`� Environmental Health Section PROPERTY INFORMATION !'(,�7 U�G - , , ,.. P.O. Box 84$ Directions to property: ` #�-f� } � � Mocksville, NC 27028 Subdivision Name: � � � � ? Phone#: 336-751-8760 %�,,i',,1'i ',1": � i� Section: Lot: AUTHORI7,ATION FOR WASTEWATER Tax Office PW:#'r���-�y�-�� SYSTF.M CONSTRUCTION , AUTHORIZATION NO: ���"��� A Road Name: � �` � � �"Zip: � `r' **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for�`""uilc�ing Permits. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section':]900 Sewage Treatment and Disposal Systems) ! , j ,--; ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION � '-'" .....��� ? i Cr ' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONPvtENTAL HEALTH SPECIALIST DATE ISSUED �._, , RESIDENTIAL SPECIFICATION:BUILDING TYPE { i r l�!#BEllROOMS �l #BATHS ��"� #OCCUPANTS �--� GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PE jLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No � t �� � r �11 �, f i' �•�s�',I-�=_... .�l J� '' , (.. ..CL� f ' ;. '` ; ' / LOT SIZE TYPE WAT��,SUPPLY "'�-''�� �DESIGN WASTEWATER FLOW(GPD) �l�-Z--� NEW SITE REPAIR SITE �' ,> �,.� .t � , SYSTEM SPECIFICATIONS: TANK SIZE ,, � GA P�J11r1P�'�A K � �GAL. "TRENGH.WIDTH � 't'' ROC ���H% � �. LI�l�AR FT •t_��i � ',r'�r�^� 1.-;��-� • �'' � „� L�;r� i�_ � ..- � `""' C � �,, i�..� ..� �' %: �, -� �,,y� OTHER.- � 4 -•T�J r�' ') � � � � ?�1 �(J .�.._ �...,...�. ,,,...... �^^ � � -`' � 1 1;:,. � � • i f r-� ) ' j ' REQUIRED SITE MODIFICATIONS/CONDITIONS: �'''`t ���'�-��""�''��'�"� �'"'� � � �`?'" r"�'""�-��� �, `�-'�� t�t-l�`w'�_;; ��L�,:.1 �±> , ti �—�-=--"4'� L.1L'.l.s- ,�-,�.,_ IMPROVEMENT PERMI�iA�,O�(� �� `�:`�� i._,.�4 %�t�""`;�`t� �`V��' '-;� f +,� ..�! ti - _} � o �.-��.1 L.�`�I t'��'"'.. l ��t� . ,`.,�.- s�"'�,,,,,, . " a � � � ,s. t.. '",-,,� r...� .-..�..--..,..%i �+ '*.{ .,�, .. _. , J j,`/ �<'�' ''. i ..._.__ . •+`, .„� �r �i. , - • "�->.,�� , , � '��/�l.l C�i.,�J��k-t�:...�►t..h.1�;� � � j__. _.__. � • � ��„\ �, �,,f °,.� 1 ,�+ �} A' �� 1',; � c �•-�y t,' �r, , ar' ) �� `z, ��� �,_ �t��t,1 i` /�,.A..- (V��IY� �i �j i ' 1 ��a.- �r ^ T � \ � � ... .y ,. ��� y _� �/� IY\1✓�' �� / +. 4 � t � ��,'� �� 1 ':\.r^r \ J�` �.�. . � .�.�-r......_... 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E �' �''.� . ._.,. .,,.- fr _.. t t. fi r , ti.-•—. ...:.:i 'M �, �� , r 1. �} � �.�.,1�'�C'"1� �t�l�� (.,i-t I L� , <; ��- __ ��.c� �. ��. _-_ . � �� -� `��' �ir�� .�� � l . . , j �^ .i , + t� _ ` (r`,:�t.��;. 1i...�`- l-�-i:,�e�,J,�,.�l���. �.�—�>�, ._ ... ����il� . � c , �- � �� '�r'-�-�'✓ ;;° ;;�;=- �-�� �`,� � � L. ;�:,�., ��� �.,1 t -_�.. �. ` ` '`�� � � ,t t ����_-_._._._. � _�� _ � � � '',-'� FOR FINAI�INSPECTION OF TH1S SYSTEM PLEASE CALL BETW EEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE ti IS(336)751-8760. 4 �" ` 't,,:' OPERATION PERMIT 51 ;%�� SYSTEM INSTALLED BY: t � �t , �t 1 : i 1 �i '` r � , AUTHORIZATION NO. 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.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY$E TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. nc►�n ovoz ce���:�a� 7//1J L,=t'��"J�.'f!_5 - �, o � � � � � � � D z 2�0� . D�� � � . . ����Ro�M��p�� .nty �ealt� Departmez�t ����`�: _ �Fu' Ex�vironme�tai �-I� 1 S �. ���;..� � a �h ection ,......,� . � ;��:: - � '_ �.o.�o�s�s � ��� � "�`. :' .� �: Z10 Hospical Street � '� � `�° Courier� .09-40�06 :�+1 +. .'�'°i'�; . ' � ' � Mockaville,NC 27028 Phone:(336).�51.8760 Fa�:(336)�751-8186 C�N SIT£�V�STEVVA3'��t CER'T��YC ON FOR DWELLINC � � CCheck One) Reptacement emodeli� Recoanectiun , Nazne: phone Nur�bcr� �2 �o.rJ � (Home) Mailing Address: oZ �Q S � � c3 �i�� ���_('Work) � �� rt,� �� �]� ��� betailed Dire�tiohs To Sita: � 7 p � � U.�,l�2 S t��3 CSL, �S�'1 lj S � `On,� � �-I � > / (r ^ � 2 Property Adciress: J�o.�L N gh�(�`' ��C�\j �C1. �C ��'�(�C� • —�--- Please Fill In The�'ollowing Info �ation Aboui T�c�:�IS?1'NG FscUtty:., , • Name System installed[Jnder: �- e��S b�aSt�� e f F$cili�: ��'rLSZ s bate System Irstalled(Month/Date/Ysar): � Number Of Bedrooms:_�_ Number Of People: 1 T5 Tho FaCility Currentty vaca�cT Yes N� If Yes,Far How Long7 �Try�nown Problems? Yes � If'Yes,�xgl�in; plcs�e�'i1i In'�he Foiiowtt�g InformAtioo About ThVNE�'Facill � O � Type Qf�acility: . i ���'��r Of Btcfrooms:�_N'utnbzr of people j -O� Rec�uested By• bate Raquested:�.02�� gnaturc) For En�vironmental Health Office Use Only Approved bisapproved � .-' � ��)� Commancs: 1 �L=�'U�1,��i•\!�6 ��i�-�. ���11��-� l'L f'1 �� �C� L7. ,� ���-r�;'�*.�.-� �� , .3 /� Environmcnra!Health Specialist . "�' f'� I3aie: �` �� . , '"The signing of thiS fa:tn b�the�nvironmental H � Si ff�s no�+a ' iended,nor should be akon as a guarantse (eXtended or limited)that the on-site wastcwater s�stem wil!function properiy far rsty�irrtn period oftime. Paymcnt: �ash Che�k Mone�Ordec # Amount:� bate: r� ' ' � Aaid$y: �j-� (�_�i �i'{�I� Rec�ived By, ��. 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