828 Beauchamp Rd T , . _ _
. � _
O
�l�ermittee's ; � ) �AVIE COUNTY HEALTH DEPARTMENT 6`�'� - �
A/,-
It*� 'f A'1� ' T_t��'� �� r.�l K Environmental Health Section OPERTY INFORMATION
— ` � ' P.O. Box 848
` l�irections to pmperty: �`a''` �� �-�"`��-��+"✓Et�`t-4'� Mocksville, NC 27028 Subdivision Name: '
���.A,�� �'�f, . t ` :;, M , r r �;�., Phone#:336-751-8760
,__..
. (.�-�7 � i�_��S.�C'_,•��.�sv. � Section: Lot:
� � � AUTHORI7.ATION FOR
(�?J t,l�'1 +� " T �"_'. J�f a.' z -., t WASTEWATF,R
_.. , S...t.,J._� �f�_•,M ',��a•'1�,:..1"��:.i C.�t' Tax Office PIN:#
SYSTEM CONSTRUCTION -
p.y (�• �" c^„ {l "" � � w. kr' t>
AUTHORIZATION NO: t:c� � � A Road Name: �'``��t �= �C-"#��'�Lip: :�t�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 applyina for Building Permits.
(ln compliance with Article 1] pf G.$..Ghapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
_. � j; ` �
s` �:�.�, c>:---,�„�f J ,,,,,,.. ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
l f;f `w • :'a ;'`�r"`. '� �'�J ��, �}"� IS VALID FOR A PERIOD OF FIVE YEARS.
ENV[R�NM N�EA ,�-ISP�CIALIST� DA ISS ED
RESIDENTIAL SPECIFICATION:BUILDING TYPE t���#BEllROOMS � #BATHS��' �#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE ''�S� T�E WATER SUPPLY 1= ..� DESIGN WASTEWATER FLOW(GPD) �"� r� NEW SITE REPAIR SITE y
!I �, �� .-7 �
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK 1L�.�GAL. TRENCH WIDTH c_"`j.? ROCK DEPTH 1� LINEAR Ff..� t:�
OTHER ""f c�l�:-1 t:;�.�{O� .1�,����
REQUIRED SITE MODIFICATIONS/CONDITIONS:Itti.Iti�i��.-�.- C`� �"'��� � �4.-�� Iv �/�r" 1"'1'� �✓'^1'�=r ti'--�-�� � ���"'
"1�-.
IMPROVEMENT PERMIT LAYOUT
----�..._ ��1 �� �..�,r }
�:�
`5���� ���T �Etx.�'� � �
fs' r'
+-�v,-�T �r� �
z
0
,, „
�(:D '��Z----"'t��
--------"""'1�'__...-.-:--"__"__._----�
�.,-- �� ___�,.-.�
�,----"_---�-_
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT � �C�L �����
SYSTEM INSTALLED BY:
, 1 v"'lT �r� ""`''�'"-
� �
--------�- � �T —
T
t�l��� � ��`� �"� t�'
�i '
H _��
� � 'A
.,�
�r ,�,�� •
• ,�
, 1 p�S�
, _:..�:. 1oO ��,.x��„
pUTHORIZATIONNO. �0 r_` OPERATI BY: AT Z �
��p .
'*THE ISSUANCE UF THIS OPERATION PERMIT SH AT'�HE SYSTEM DESCRI D ABOVE HAS BEEN INSTALLED IN COMPLIANCE
W�'H pRTICLE 11 OF G.S.CHAP'TER 13 , ION.1900"SEWAG� TMENT AN SAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANI'EE THAT THE SYSTEM WILL FUNCTION SATISFACTORI IVEN PERIOD OF TIME.
DCHD 02N2(Revised) .�`_��� /�} ��-.�/'`-"' � � � L C'
� /'w'_/�, _' � e.�..].._ � J
. r1.Y�-��3--
, � �7 � �
�-n J a-u'
��-, � �< ��� �� C�.J 27zi
,` � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTIO � J � �Z
� �� 4� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ���� ��C� �7 PHO E NUMBER ��7 /..�_��
��',� � �� �Y-�
ADDRESS �SZO ��1� '�W A SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM iNSTALLEp 'f�' 7Z- NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS � 2�� NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ��1�-� SPECIFY PROBLEM OCCURRING /9�C.2) �l�i� � �
�'1���
DATE REQUESTED � INFORMATION TAKEN BY
This is to qrtily that the information provided is conect to the best of my knowledge,and that I undsrstand I am responsible for all chargea incurced from thi�npplication.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
�.�,.,ro3 YQ�/ ���7 �
�l
'1d �\ ;�, �
�` � �
y b
��
��!
, 3ti
� �
v ��._ '�.�,
- �_......��
'L�
�
�---- __� , Ci
� ' ��
� �.C�