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:AUTHORIZATION NO: 'T '� DAVIE COUNTY HEALTH DEPARTMENT .
Environmental Health Section PROPERTY INFORMATION
"Permittee s •- / P.O.Box 848
Name: L'/ G'�t iG' Mocksville,NC 27028 '. Subdivision Name:
Phone# 336-751-8760 '
Directions to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name: Zip:'
*NOTE**'Ibis Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building-Pen-nits.This Form/Authorization Number should be presented.to the Davie County Building Inspections,
Office when applying for Building Permits.
(In compliance with Article I l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
l ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SP CIALIST DATE ISSUED
1 t .r� � j'r� +. t t c .{..<j.Y �, "�r_,+ s :.�.:, . .. ..t. i + .• - :.:...wr�r r.B.f.`,• -r. .
167 DAVIE COUNTY HEALTH DEPARTMENT�/? 2
A
IMPROVEMENT AND OPERATION PERMITS ' PROPERTY INFORMATION
,~`Permittee's fir'? ,
.�°"1 l'! ('<i.- /' Subdivision Name.
Directions to property: ��t/` c ,i/ "{iJf l-fr:. Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: Zip:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r/ .i `� . � ,v.�' .r �" ", Il PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH S E`CIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM. -
RESIDENTIAL SPECIFICATION:BUILDING TYPE. #BEDROOMS '#BATHS /F �- OCCUPANTS 4GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE' #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY t DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEP THZ(- LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT �I'
*APPROVED tIEAI�' ILTI:R #RIS' SE tRR S) IF 691 BELOW FINISHED GRADE*
F
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH D OR AL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00 1:30 P.M.ON THE DA IN LA ELEPHONE#IS*7"W6 A.4.&a(�
XXXXXXXXX
OPERATION PERMIT h
INSTALLED BY:
�
n
a �
AUTHORIZATION NO..tet''OPERATION PERMIT BY: � DATE:z �YY,
**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 BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised) .
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71A DAVIE COUNTY HEALTH DEPARTMENT/�
i IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee'sM5le
Subdivision Name:
Directions to property: �``:'� �''-°' d
Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: Zip:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
t t ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
'' .r a► '- ='t i �'' r` /t'' " r` "�`;' PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE 42� #BEDROOMS #BATHS 1. S '#OCCUPANTS 4/ GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ��-� DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK 'GAL: TRENCH WIDTH,'_ ROCK DEPTH/ '� LINEAR FT. de)
a
OTHER '
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
i *APPROVED EFL IL *RISER(S) IF G" IIELCIId FIfJISli Dw,GRAd}E ,
S�041 A.
-
�,wG
ti. .
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH D T FOR AL INSPECTION OF THIS SYSTEM a ,'
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DA I L LEPHONE#IS04�67rt,I;Zb�
XIIKXXXX)IX
OPERATION PERMIT
INSTALLED BY: / 'Iv"
l� X
(=-
AUTHORIZATION NO.�('�L,AOPERATION PERMIT BY:� A DATE: (I G
"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 BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
ADDRESS SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED_ NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.11V
plNW991 -rN-od66 I_ ,10r96�