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'Permittee's�� DAVIE COUNTY HEALTH DEPARTMENT 7
"� Name:� � t�`'r<-''r,'�'/� ��1'r.`-�'�; Environmental Health Section PROPERTY INFORMATION
`�� �-� �-�� ,) ' P.O. Box 848
Directions to ro ert /`y�� "7 �i�'•��►
P P Y� � � � 1�1ocksville,NC 27028 Subdivision Name:
,f i,%,�� . � f� ,'� Phone#: 336-751-8760
,/-`'t�� t'"',� �,;.�;),�s�, :='+" f-k' Section: Lot:
AUTHORIZATION FOK
� ✓• - ,�° , Vb'ASTEWATER '
���� 'r��'��'� F`' `"�' �� SYSTF.MCONSTRUCTION TaxOfficePlN:# - -
AUTHORIZATION NO: ��� � A Road Name: Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
ro issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections �
Office when applying for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�,,� f ,� � M"\�'fl�r � .��'" ,. ..-.. ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
L`"�•, i•�_�__ � ;�v'._�.r-'i r:,,,r�'/"`�} r'=c r� „�i�r" IS VALID FOR A PERIOD OF FIVE YEARS. ,
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS #BATHS � #O�C�UPA}VTS GARBAGE DISPOSAL:Yes or No '
��e i'„S'�l�c,�„h.�l �'1�1'�- !�C-�O %�<-��SrrJ��.
COMMERCIAL SPECIFICATION: FACILITY TYP #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes o No
LOT SIZE TYPE WATER SUPPLY , DESIGN WASTEWATER FLOW(GPD) ��� NEW SITE REPAIR SITE v �
� �
SYSTEM SPECIFICATIONS: .TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��� � ROCK DEPTH /�-J LINEAR FT.�a�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: ' �
IMPROVEMENT P RMIT LAYOUT �p� � I
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 830-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
�
OPERATION PERMIT ����
SYSTEM INSTALLED BY:
Yw �
OPERATION PERMIT BY: DATE• �`� �
AUTHORIZATION NO. .
L,�z�� ��� ,
*'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A I
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ,
DCHD 02/02(Revised) . . - �' '..
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�n DAVIE COUN NVIRONMENTAL HEALTH SECTION
r �,`��J` -�w � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
�� �1 ,y
NAME � ' l/CPi � /a' lcl��'lL�i PHONE NUMBER i��r�� �/
ADDRESS ���� /v���� (/� SUBDIVISION NAME
�d /Z�`/� / v�l; ����-��7J /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 certity that the information provided is correct to the best of my knowledge,and that I understand I am responsible tor all charpes incurred from thia application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93
� .� .-/ �� S'�ou� � • �u,��; /--�°�o2�a���r �6/�' �
� ���� � �,��,�t�r DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION � '�f" p��,�—
U "� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �� ���I `V�/1 clsi'�� 1��� PHONE NUMBER �I���- 31,Q��
ADDRESS � I� �I�e� L1n• SUBDIVISION NAME +J I�
LOT # `�.
DIRECTIONS TO SITE �J t�>� ��Y�1Y�l�v((� �-�. L b� �i�(le�/l��� � �
C�� `I � � �
DATE SYSTEM INSTALLED ����_NAME SYSTEM INSTALLED UNDER PIID� -�p�l ��V� �E���V�1 l
TYPE FACILITY C�� � ���+ NUMBER BEDROOMS "-- NUMBER PEOPLE SERVED
TYPE WATER SUPPLY C� � OU�V� SPECIFY PROBLEM OCCURRING���L �1I�� l�� "�NGtd
� �n�ve. ���v�npea �.��s Y���e� �iti4�1 �� ��.-��e���.,. �ne� do��`� K�nuw v�v�e��e��s cu�e .
DATE REQUESTED �' �� •O4' INFORMATION TAKEN BY__P��,�\SOV� COS"�
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 irom this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93