1238 Angell Rd � •`Permittee's,r-- , ,�-% DAVIE COUNTY HEALTH DEPARTMENT � � � �/`� J �_� ' s
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Name:� �-� �'r f� r'`4'.' � Environmental Health Section PROPERTY II�iFORMATION
« �� / �.: P.O. Box 848
Directions to property: ����-�` �j!��✓f.�%'� �:�`�.� Mocksville, NC 27028 Subdivision Name:
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��'r;�" ,1`r�f L yi,%;1;;� � ,,, � /�,,,%`f ,',r'%�'� � Phone#: 336-751-8760 Section: Lot:
' 1 AUTHORI7.ATION FOR
�`� f• ✓� ��, WASTEWATER
�';' i/;..'�'. /�. . /'_ f � Tax Office PIN:# - -
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SYSTEM CONSTRUCTION
AUTHORIZATION NO: ���� � A Road Name: Zip:
**NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.7'his Forn�/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�j' /� f - , r-' -- ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
��X/1/! �Ir°; f r '�r':l tf: '!� ' "� f/ .,�/:,�,:',f'
r /� �,t, �.; � ,f ,.a IS VALID FOR A PERIOD OF FIVE YEARS.
�ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE�� #BEllROOMS � #BATHS � #OCCUPANTS � 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 j�
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��ROCK DEPTH �s", LINEAR Ff.���� •
OTHER �' \
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT
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**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 (336)751-8760.
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OPERATION PERMIT � b
SYSTEM STALL BY: G
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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.CHAP'fER 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) . . . . � . '
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� . � • � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME S�t�t�.. �o�� PHONE NUMBER �`�g' y g�� q
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ADDRESS_ !� 3Y Rhc���l � SUBDIVISION NAME ��
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� U���C. Z7 o Z�`' LOT # �
DIRECTIONS TO SITE Is�cl ►� I •R.� Cur►a. � T• �� �►^ccll � ' Q,P,P.�,l• ��Z �'►��l-t. �n�.-�j- �
-�c:rt 1, ru c.� l.l an a� Wl+;tc. w�.�.Q. b� �► I z 3 Y,) �
w4► 3v y r� •
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DATE SYSTEM INSTALLED s��.•ct NAME SYSTEM INSTALLED UNDER "
TYPE FACILITY }�v►.�1� NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED -3
TYPE WATER SUPPLY 4�e.�\ SPECIFY PROBLEM OCCURRING Co w.r,c �o � P D F �
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(.�v-a u h.cQ �'
DATE REQUESTED G-.'t - �3 INFORMATION TAKEN BY �
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I a�le for all charges i�curred irom this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93