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219 Ben Anderson Rd ' Permirt�e's ,.-, ¢�1. � DAVIE COUNTY HEALTH DEPARTMENT � Name: ����- t, Environmental Health Section PROPERTY INFORMA �IV�,�1��s -, P.O. Box 848 I I I �" Directions to property: �-w'�-��`� �r�.� �-0�-" Mocksville,NC 27028 Subdivision Name: '.;�� ;�;{Y; -�v��„� �, � �;�: �- Phone#: 336-751-8760 �� �" �� +� Section: Lot: j j. ;, ; h AUTHORIZATION FOR _.'i�.iL:�'�, ;H:.,% j;��� ��.�� P�`ti�'�;;�:.�L„� WASTEWATER SYSTF,M CONSTRUCTION Tax Office PIN:# AUTHORIZATION NO: �a��� � A Road Name.-= �'{ `'�`�'��''`��,�' �{���,� �`-:�' z�p.:� l **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 Forn�/Authorization Number should be presented to the Davie County Building Inspections Office when applyino for Building Pennits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems) ,,�, ,, •.---...,, `°` "�; ***VOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION :.�I~'� _�°�;•' �`. l�l ..'�crl.%(,�, --a�� l�'i ti ✓`' ��--�-��. IS VALID FOR A PERIOD OF FIVE YF,ARS. ����ENVIRCSNNIENTAL HEA'LTH SPECIALIST DATE ISSUED RESIDENfIAL SPECIFICATION:BUILDING TYPE !� !qs`�#BEllROOMS '� #BATHS � #OCCUPANTS T_.. GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE I�� ^r`r��TYPE WATER SUPPLY�'`��-�-L- DESIGN WASTEWATER FLOW(GPD) � ���7 NEW SITE REPAIR SITE � SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �-''�', ROCK DEPfH ��-„ LINEAR FT.������ !�s �ts terl in 1.5A l�CAC 18A.19b�(5 OTHER �JCcBpted SV;�t��ms i�lay also b� usec� REQUIREDSITEMODIFICATIONS/CONDITIONS: �NG'�'��.-�--- �1 �.!.��.1...�:_ ���.-��� .��t�,���4=l.lca-�- 1•)�� IMPROVEMENT PERMIT LAYOUT ����_ � �� „ —_ � -t � I -�'��1��r��� C�C�`t� i ;, f_ r-�.�� �-f��r..�.�i i`G(�'i-t� ��i��� � ; f(!;V`�t J ' �c �t:Ti} ...�, -f; -- � ! �i t-�vr-�i ��t r _� FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT �^ _ ,�•-y�r r1 A ,� .,() SYSTEM INSTALLED BY: ���ZJ� �� Ll-'^ � I �' ?1���I—�..._ c� � � ; I-le��-^ Qvi�� �� �� ,...^I__,_____1 C��� � ���'T AUTHORIZATION NO. � `��� OPERATION PERMIT BY: DATE: I � •"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY DESCRIBED BOVE EEN INSTALLED IN COMPLIANCE W1TH ARTICLE 1 I OF G.S.CHAP'fER 130A,SECTION.1900"SEWAGE TREATMEN 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 02ro2(Rev;sed) � . yt1�" 1TC-_3 - '`'Periniif�e's .,.-, 1 DAVIE COUNTY HEALTH DEPARTMENT � � Name: ` ;'3��-y �' �' � �C Environmental Health Section PROPERTY INFORMATI N - - : � , , P.O. Box848 � �1��� Direcfions to property: '� `'t'''-� �, ` �-�M�' Mocksville,NC 27028 Subdivision Name: � - �� �, Phone#: 336-751-8760 �' z 4�,: , 1 ;�, = � ;.# �;,:,} ,,�, Section: Lot: — " ' AUTHORI7.ATION FOK ' , f ,>�.} r ' � � - �' WASTEWATER -;-.�.� '*.. ° E�-:, •r � ,'`~�. � Tax Office P(N:# - - ' SYSTEM CONSTRUCTION { Q���i � �'���1,���,.Jt=, �� � :``, AUTHORIZATION NO: t� Road Name:- �"z Z�p .- **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 applying for Building Pennits. (ln compliance with Article 11 of G.S.Chapter I30A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) 'r' f J ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION �� -`'; y� " '`' �.--�--.., I I;��t ,'''�'C� IS VALID FOR A PERIOD OF FIVE YF.ARS. ENV[RONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIF[CATION:BUILDING TYPE�{,L�#BEUROOMS #BATHS � #OCCUPANTS_�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE , #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No " n ���ti � � LOT SIZE ��-' n^ TYPE WATER SUPPLY�J���- DESIGN WASTEWATER FLOW(GPD) �.- �-� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��"'', ROCK DEPTH �'-- • LINEAR FI'. �f:f_�� OTHER t.�-, � r ,_ REQUIRED SITE MODIFICATIONS/CONDITIONS: '�""' '���-�- �;,� �..-!�1'*Y�r-l��t�... �✓6=�ti_�' ���'��!'i-�(>v4�- !n)�;;t #,� IMPROVEMENT PERMIT LAYOUT /''.....-----"„' '�,��1t,.l.�. w �"; \� + � � �....w_��'�.�.."»'..., .�.��-�'..f.....�.,;-`"..:,...._,.,y i -, 3 r� ���1�t ���...K.rJ�U�'< � _... �i I_� �- ` ` f � i � � ��{ t✓���C �i(�.���k.�t r�'�i'i �-� ,:.i�,� � � ;�_ E � �=-U�`'�= � ; � 'j� � 1 � e 1�: 1:.��r r. ;� �._. ? � i' � ��_i_ � t✓ . � � i , ►� ��.:_:��; �r� � � � . �'_``�� � ! � � . � FOR FINAL INSPECTION OF THIS SYST'EM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. F OPERATION PERMIT ��;-^�� ,�, A '�`�� SYSTEM INSTALLED BY: L��� �y� � �, = �-=� '��f� ��____�.I_ zc � .. s c J c` � , . � a—Ic��= r �V t��� ��CD ������ �.t.t��� q F�p�7 T A , � AUTHORIZATION NO. ����"� OPERATION PERMIT BY: l DATE: I � �f7 *"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY�T/ °DESCRIBED A OVE 5'SEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENTAND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. oc[i�ozro2����s�a) �„ %� '' /(�fr� >7C'� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) GJ�, r NAME �ILL �Z-'�L� PHONE NUMBER / �Z- �j� 9 ADDRESS 2�� �" �''���-S`�� '�'� � �'`���UBDIVISION NAME � LOT # DIRECTIONS TO SITE U/��N � �� �N � �U� L � �� �9rL.�'K' ' �n /� , - �U� i'-- � W�l�,�o� o-� n. �tr I.� 1 � , DATE SYSTEM INSTALLED �� NAME SYSTEM INSTALLED UNDER �t�'�` TYPE FACILITY � ���'� NUMBER BEDROOMS � � __NUMBER PEOPLE SERVED 2 TYPE WATER SUPPLY �la �_ SPECIFY PROBLEM OCCURRING �i�QU�� , �C�{G '�Co v�Q �� �-�raS� , DATE REQUESTED � t� INFORMATION TAKEN BY %� Thia is to certi(y that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges(ncurred from this applicaGon. 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