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193 Shady Grove Lane Lot 15AiJTHORIZ.ATION NO: 4 DAVIE COUNTY HEALTH DEPARTMENT al YPAs Environmental Health Section PROPERTY INFORMATION Pernuttee s `l F /� O. P Box 848 Name. vi)C�6fIL> ( onLnIQdG7lv.� /NG, Mocicsville; NC 27028 ; Subdivision Name: S,a 4 ntr GaOVC Phone #: 704-634-8760 Directions to property: PAL TO EI tJYSection: Lot: /,�'n_+ AUTHORIZATION FOR ' Q "rlXll t�J -Tt9A W !J^) ,: WASTEWATER Tax Off ee IN•#�SVI _g - %q' : 1 J SYSTEM CONSTRUCTION. boat— Mias V -6n? bN �tIJaOY�o � Road Name:�140Y(c�ti` l t�Zip: **NOTE**: This Authorization for Wastewater System Constriction MUST BE ISSUED by the Davie County Environmental Health Section prioi to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections" Office when 'applying. for Building Pernrits: (In compliance' � %th' cle I of 6S. Chapter 130A, Wastewater Systems, ,Section .1900 Sewage Treatment and Disposal Sys tems) ***NOTICE***THISAUTHORIZATION FOR WASTEWATER CONSTRUCTION !_ 1 IS VALID FOR A PERIOD OF FIVE YEARS. :ENVIRON E LHE ! TH'SPECI LI DA ISS ED . 1143 ��� �.• DAVIE'COUNTY HEALTH DEPARTMENT •1'. - IMPROVEMENT AND OPERATION PERMITS �. Perptt ga'l. 1v' \' PROPERTY INFORMATION .Named"=r..iJt:b�W'¢, (_.G 7 vl7t�� �NG Subdivision Name: !Sj4Any'C12aJG Direcdons to ro` 1�,�G i ��� P pert : Yyoy Section: Lot . •- E PROVEMENT / o ^t `i arl U4%. `T t.R AI�/ 1 zJ �' PERMIT Tax Office PIN:#�7t� `J�'" - ! %ti //i� n li(ftt M�f.`fS in, /L-:) Road Name. t1Ar`r�t2e.4: {nlzip`:'%ic to "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 Wobtained from this Department prior Loathe t co ns tructiordinstallation 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 I 1 t k-7 PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVI166NMENTAL HEALTH SPEC IAL,I T DATE ISS D SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE $✓ INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 002M6 # BEDROOMS --a # BATHS Z11-# OCCUPANTS GARBAGE DISPOSAL: Yes oro COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHINI' # SEATS INDUSTRIAL WASTE: Yes or No LOTSIZEJ!�b� TYPE WATER SUPPL,,Yd210YDESIGN WASTEWATER FLOW (GPD)3� NEW SITE REPAIR SITE • SYSTEM SPECIFICATIONS: TANK SIZE �������� GAL. PUMP TANK GAL. TRENCH WIDTH �s; ROCK DEPTH IZ // LINEAR FT.3DO t OTHER `-DISTF-16If IQA L OY. 3 bad ivm(,.-S ' REQUIRED SITE MOI IMPROVEMENT PERMIT LAYOUT 1)ZIJG Ew x Ir15'fALL Ltr�.S 9'a.C. kt:e:P vJT• /ri bFF i3AcK OQaOG7.vE` /defwdA s' t�+�'r wnr �� a e ixf'1'eIIB -;e4 are e1/)k-14re4-/ neVA ss' 9'aGt ss' 9'04C q3 ss' qo.q aZ "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 (704) 634.8760. OPERATION PERMIT 22 - SYSTEM INSTALLED BY: �P%J� IiSry i TAV.FSQ� - I.�pJSc kT i lit s n � r AUTHORIZATION NO. 114 OPERATION PERMIT B DATE: �)._/. - •!TETE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT I 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) s APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC 4 Davie County Health Department \�� n Environmental Health Section D 15 P.O. Box 848 NOV - 7f Mocksville, NC 27028 (704) 634-8760 3 `/ It'-' ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE S ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed (/ Contact Person LJ t C R �� (-C� Mailing Address ` r ) Home Phone �� 9 �- el -2 City/State/Zip �i /dvr.1 d -AC 2:2aO 6 Business Phone 7 V6 r 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [ ] Site Evaluation City/State/Zip 1 --ll provement Permit & ATC [ ] Both 4. System to Serve: Ll?gIouse [ ]] Mobile Home [ ] Business [ ] Industry 5. If Residences # People �i - #Bedrooms_ , # Bathrooms_ [Washing Machine [ ] Basement/Plumbing M' sement/No Plumbing [ ] Other [-rgishwasher [ ] Garbage Disposal 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats— Estimated Water Usage (gallons per day) Cou 7. Type of water supply: [ nty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [qN-0 If yes, what type? iii\J tt Jr=K it CLAI UA OLLL rL AV PROPERTY INFORMATION REQUIRED: *** IMPORTANT **WOF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: wA WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # 47 W Property Address: RoadII I{fame L / A- d r� cs-- I City/Zip If in Subdivision provide information, as follows: Name: Section: Lot#: Is— This s This is to certify that the information provided is correct to the best 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, of if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by � 1Orld l� to conduct a testing procedures as necessary to determine the site suitability. DATE SIGNATURE l/ PGF Revised DCHD (06-96) THIS AREA MAY $E USED FOR DRAWING JOUR SITE PLAN: I toy�r—, by Henry S ore,Rogster of Deeds a Lthe Fmcd plat for 'SHADY GROVE'. Subdivision. 157 4 er T ... Malrml^ County Planning q, , 602'72<' S` 84 TOTAL j 1 49.17 Zl28 50 xoy :rra. 4 138.00 4-- I 7 ' u i1 v Al �4, ;:-o W, �Iw Lu 0, IT O+ 1, 0, f ;'i iv p LOD . 1p+OD (a N 4 OL C11 C�) sv I 124.9L JT 9 - - - - - - - 3 25' 7 i C: M C J OF WAY IG TOT N ' -LL-10 —5. 9,� 9' 53' 49" E 50 � 20 PUBLIC ROAD - 9'53' 49" W -r� C, D r. AL3_05.94' C, Vi ILI -7 140.00 150.94' 1 iEg41 6 -15,00 Ld .%a :00 41 Z7 (a V— V, <.L 3D o'a, --yLL 7 '.140 Qu 66.7 ' E- L -614-77! 1�'N -7 37 141 1111 '. CONC. ir ''Vj,iI.CONTROU A i;�-:;�coRNER `-, :4 &� �lXV I L -z� v % 2000 F.T TANCE? 8. DAVIE,-COUNM; 9. ALL-,STORM'SEV CABLE., TELE\ASI STREET RIGH DEPARTMENT -':OF TRANSPORTATION 10. DUKE POWER H DIVISION'OF HIGHWAYS;' 11 NC DOT ,WILL ,'O PROPOSED ROAD CONSTRUCTION STANDARDS CERTIFICATION ' 12CUC"DE= ANKI ,,-,,,.:,'H2O.R[,ZO,NTAL-CURVE DATA'TABLEt� 7..' LONG ;CHORD ARC URS: CURS' DISTANCE ::- BEARING :UENGTH RADIUS DELTA TANGENT S-- 0*25' 0" W 235.55'. .1975.00- 50' 0" 117;91' 4;C: 8 i148r32' N ,1;44' 4".E -148.35' 2025.00' "4 11'51" 74;21'� Z ,C'C .��93.15'4' N-,� 40'W:W - ;1' .93;16' 2025.00' 12'38'. 9"' '46.59. - 'C �W . . �'-,26'OV,'x S' - 9- 31- 45" W .:26.01'. 2025.00' 0-44'.-'9- ,: 'El ' ;il 85", S:- 7729 38 W 117.87-1 2025.00' 3'20' 6" .58.95! rC:F 2* 44' 27" W � 218.11' 2025.00' 6 10'16': 109A (3' ?..93:83' ;1' 40'.21" E. 93.8 2025.00' 2*39*19" - ,r 46. 93 t.c-., H :,58:33'-: ,S. N' 2*. 9.1e W. 58.33'. 1975.00 A-41'32".. 29 17 2543' 0"X7,3043". E: .125.45-- 1975.00' '4-38'22": -1�62.175"'�', �223.9 3 5. 3W54-, E' .,224.05' 1975.00' 30- O'� 41215,� C_ K 36.73 ,5 'g. N 'Zl O'E 36.73- 1975.00' 1*:3'56, 8:3-6! , " _.0 L. i I 127.55' N �2* 26 48"'E 35�00' -45' 557", 14.53 ','53Z6 M.330� �%,7310"- 18 . 1 N,-1 E' 81.98' :50.00'.' 93, - 56' 26" T� N. 9.�150 67, ,N;, 69723-.20",�PW 53.14%, �50,00 60'53"21", 29, 39 2C. 0 ; . � -4 -49A 4; .; S-'50'43,51 'W 51.37"" I 50;00 58'Z2'17"-� ,C. C '47.33'' S 6'.57'13" E 49.30' 50.00- 56*29'50" ;':26 86 C-1, Q. 26.84' S 12'39' 9" E. 27.55' 35.00' 45', 5'57"* 14.53'1: " :'tl 238.39p, N.-0-25' Ow E 238.53' 2000.00' 6'50' 0": 11 9.,41 C2 449.24''IN 3-26'55- El 450.19' 2000-00' 12' 53' 49" 5- 2000 F.T TANCE? 8. DAVIE,-COUNM; 9. ALL-,STORM'SEV CABLE., TELE\ASI STREET RIGH DEPARTMENT -':OF TRANSPORTATION 10. DUKE POWER H DIVISION'OF HIGHWAYS;' 11 NC DOT ,WILL ,'O PROPOSED ROAD CONSTRUCTION STANDARDS CERTIFICATION ' 12CUC"DE= ANKI \; .t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME (/ O ADDRESS Cy PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well _ Community Public '- Evaluation By: Auger Boring _ Pit Cut FACTORS 1 2 3 4 Landscape position Sloes HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ) Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: dl'3 EVALUATED BY: Xk/_z LDNG-TERM ACCEPTANCE RATE: i OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope Texture S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty <.lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay- SIC -Silty clay C -Clay Moist VFR-Veryfriable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet NS -Non sticky . SS -Slightly sticky S -Sticky VS -Very Sticky NP -Non plastic SP -Slightly plastic P -Plastic . VP -Very plastic Structure 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 ' OPERATION PERMIT ,. Davie County Health Department -210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Jay Hooks Address: 193 Shady Grove Lane City Advance. State/Zip: NC 27006 Phone #: (336) 751-6751 Property Owner. ,Jay Hooks Address: 193 Shady Grove Lane CRY: Advance 'State2ip: NC 27006 Phone #: (336) 751-6751 1 Address/Road #: .. Subdivision: Shady Grove Phase: Lot: 15 Drain field 193 Shady Grove Lane Field ._ Advance NC 27006 Directions 'System Type: INFILTRATOR QUICK4STANDARD Structure: SINGLE FAMILY Hwy 164 E, Left on Hwy 801 go approx 3 miles Odell 5 _ Myers Rd on right, Then left on Shady Grove Lane of Bedrooms: 3 a 0 0 ft. Certification #: 1108 # of People: 3 Spacing: 'Water Supply: PUBLIC — 9 Inches O.C. STrench FeetO.C. 'IP Issued by.: 'System Classification/Description: Trench Width: 3 Inches — gFeet TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) 'CA issued by: Date: Sap r oliteSystem? QYes ®No Design Flow: 3 '6 0 , DistributionType:GRAVITY-SERIAL Pump Required? QYes (E) No Soil Application Rate: 0 3 'Pre Treatment: Drain field Field ._ Sq. ft. 'System Type: INFILTRATOR QUICK4STANDARD r"'TNitnification No. Drain Lines 5 Installer: Donnie Lakey otal Trench Length: a 0 0 ft. Certification #: 1108 Spacing: — 9 Inches O.C. STrench FeetO.C. 'EH S: 2140 -Nations. Robert Trench Width: 3 Inches — gFeet 0 6/ 1 0/ a 0 1 5 Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 _ Inches Miriimum Soil Cover. _ a .4 Inches Approval Status Maximum Trench Depth: 3 6 APprtiVed❑"Disapproved Inches Maximum Soil Cover. a q Inches CDP File Number 121989-1 County ID Number: H8 -060 -AO -015 Manufacturer. Dosing Volume: Septic Tank Manufacturer. PT: Draw Down: Lat. Certification #: Inches Gallons: Long: STB: 'EHS: Date: Gallons: Date: Installer. Date: ❑ No Yes ❑ Certification #: RiserHelght: ❑ Yes ❑ No (Min.6 in.) 'EH S: 'Filter Brand: Yes ❑ NO ElYes ❑ ST Marker: [I Yes ❑ No Date: Reinforced Tank: ❑ Yes ❑ NO " Approval Status Supply Line Yes Pipe Size: No inch diameter Installer: O Approved ❑ _Disapproved' t Piece Tank: ❑Yes Yes ❑ No - Pump Type: Pump Tank Manufacturer. Dosing Volume: Installer. - PT: Draw Down: Certification #: Inches Gallons: 'Chain: 'EHS: Date: Date: RiserSealed ❑ Yes ❑ No Yes ❑ No RiserHelght: ❑ Yes ❑ No (Min.6 in.) Approval Status einforced Tank: E3 Yes ❑ NO ElYes ❑ Approved❑;Disapproved No 1 Piece Tank:. ❑ YeS _ ❑ NO Yes ❑ No ❑ Approved O K Disapprovetl Vent Hole Supply Line Yes Pipe Size: No inch diameter Installer: Anti -siphon Hole Pipe Length: Yes feet Certification #: *Schedule: 'EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑YeS ❑ NoApproval Status r ❑ Approved ❑ Disapproved Pump Type: Installer: Dosing Volume: - Gal Certification #: Draw Down: Inches 'EHS: 'Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ElYes ❑ No .: ,a Approval ,Status s PVC unions E] Yes ❑ No ❑ Approved O K Disapprovetl Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No CDP,File Number 121989- 1 1 County ID Number: H8.050•AO.015 NEMA4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes '❑ No Certification #: Box Adj. To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ N0 *EHS: Pump Manually Operable ❑ Yes ❑ ND *Activation Method: Date: Alarm Audible El Yes ❑ No p;'Approved❑ Approval Status Disapproved Alarm Visible ❑ Yes ❑ No i 2140 • Nations, Robert *Operation Permit completed by: n Authorized State Agent: Date of Issue: 0 1 / 0 8 / a 0 1 5 C7— Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 at. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE IIA. sewage septic system. Rule .1961 requires that a Type. TYPE II a septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER .... Minimum System Inspection/Maintenance Frequency ByCertified Operator: WA Reporting Frequency By Certified Operator. NIA Rule .1961 requires that a Type IV and V septic systems designed for a homelbusiness owner must maintain a valid contract with a public management entity with a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing UlmportDrawing **Site Plan/Drawing attached,** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Operation Permit CDP File Number: 121989-1 County File Number: Hs osano o1s Date: W W ` Q Inch Scale: OBlock QN/A i CONSTRUCTION = -For office use onto '-• —R AUTHORIZATION •CDPFileNumber 121989-1 Davie County Health Department County ID Number. H8-050-AO-015ital Street210 HosP 0W.,-t Evaluated For: REPAIR P.O. Box 848 Township. 11� Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 6/ 2 6/ 2 0 1 8 Applicant: Jay Hooks Property Owner: Jay Hooks Address: 193 Shady Grove Lane Address: 193 Shady Grove Lane City: Advance City: Advance State/ZiP: NC 27006 State/Zip:.NC 27006 Phone #: (336) 751-6751 Phone Property Location & Site Information . Address/Road #: SubdNisionot� 193 Shady Grove Lane Advance NC 27006 Directions Hwy 64 E, Left on Hwy 801 go approx 3 miles Odell Structure: SINGLE FAMILY Myers Rd on right, Then left on Shady Grove Lane # of Bedrooms: 3 # of People: 3 •Water Supply: PUBLIC , System Specifications Minimum Trench Depth: Inches fication: rSaprolite Minimum Soil Cover.,.. Inches ystem? ®YesONo Design Flow: Maximum Trench Depth: " Inches Maximum Soil Cover: Soil Application Rate: Inches *System Classification/Description:'Distribution Type: Septic Tank: Gallons 1 -Piece: OYes ONO `Proposed System: Pump Required: OYes ONo, .O May Be Required Nitrification Field Sq_ ft ___fran ank: Gallons No. Drain Lines 1-Piece:0yes ONo Total Trench Length: GPM—vs— ft.TDH. ft. Trench Spacing:_ OInches O.C. Gallons Feet O.C. Dosing Volume: _ Trench Width: Inches 8Feet "" _ Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF ..OTS -I' OTS -II. Septic Tank Installer Grade Level Required: OI OII 0111 0 I Pagel of 3 CDP File Number 121989-1 County ID Number. H8050AO.015 ' ❑ Open Pump System Sheet Repair System Required: ®Yes ONO ONO, but has Available Space rDes'ign Inches 0. Trench Spacing: 9assification: pS Feet O.C. Trench Width' 36W Inches Flow: 6 0 — 8Feet Aggregate Depth: 2 4, inches lication Rate: Minimum Trench Depth: 4 g Inches *System Classification/Description: .TYPE II A. COW SYSTEM (SINGLE-FAMILY OR 480 GPO OR LESS) 'Minimum Soil Cover.Inches Maximum Trench Depth 4 8 Inches *Proposed System: CONVENTIONAL Maximum Soil Cover: Nitrification Field Inches - Sq. ft. No. Drain Lines 'Distribution Type: GRAVITY - PARALLEL (eq.d-box) TotalTrench Length: 2 _ 0 A ft Pump Required: Oyes ONo 0 May BjeR equired -II 'Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 'Permit Conditions The issuance of this permit bythe Health Department in no way guarantees the issuance of other perrnits.The permit holder. is responsible for checking with appropriate governing bodies in meeting their requirements. - This Authorization for wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe Issued atthe sametime the Improvement permit issued (NCGS 130A -336(b)} If the Installation has not been completed during the period of validity of the construction Permit the Information submitted In the application for a permit or Construction Authorization Is found to have been Incorrect falsified or changed, or the site is altered, the permit or Construction Authorization shall become Invalid and maybe suspended or revoked (.1937(8)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, installation, operation; maintenance, monitoring, reporting and repair (1938(b)).- Applicant/Legal Reps. Signature Required? OYes ONo - Applicant/Legal Reps. Signature Date: 2244 daywalL Andrew DatOf ISSue: 0 6 2 6' 1 2 0' 1 3 'Issued By: e ' d Authorized State Agent5�� L.OI. I�tMafld�9 Malfunction Log OYes OHand Drawing OimportDrawing TotalTime:(HH:MM) **Site Plan/Drawing attached.** 0 , 1 0 0 Minutes Page 2 of 3 Hours S-10- CKS issued - repair CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 klocksville NC 27028 LI�caaa•in�a f1 r....,... ... T..... ... �`...,�.:.. ...t:..., A..4 L,.. r.�.,1�.... CDP File Number: 121989 - 1 H8 -050 -AO -015 County File Number: Date: 06/26/2013 Q Inch Scale: . QBlock Page 3 of 3