474 Bethel Church Rd � peniu'�e's„�:�"� ,y- ,,�,,i ; . , DAVIE COUNTY HEALTH DEPARTMENT �'t'��°'�G �s
Name: l''11�,�� ,`� �/'� : :/i.�i%< � Environmental Health Section PROPERTY II�IFORMATION
�` y, ' ; ; P.O. Box 848
Directions to property: '�`�;��" �� '�' �`.� � ` �,f` �"! �locksville,NC 27028 Subdivision Name:
'? � '- Phone#: 336-751-8760
.r�,,'�� � r,t G,,,r,��` .� Section: Lot:
'AUTHORIZATION FOR
�f; ry;.. 1 . , � ._ ,� ,f�` ^ .. �: � i% ,'� WASTEWATER Tax Office PIN:# _ _
SYSTF,M CONSTRUCTION
AUTHORIZATION NO: ��.�� A Road Name: Zip:
**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 Fomi/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Artide I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
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: f' ��. , : f' � ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
ff�"�i}-�',(�.+ ','',-�1""`�'��f � ,� '�'r •• ..% �N�� �� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEDROOMS�_#BATHS �._ #OCCUPANTS `� GARBAGE DISPOSAL:Yes or No
i�
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
J
r-�''�.C DESIGN WASTEWATER FLOW(GPD) �C�n Q NEW SITE REPAIR SITE �
LOT SIZE TYPE WATER SUPPLY.��
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �'y� ROCK DEPTH�.� LINEAR FT. ��
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT r , �� � /
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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.
OPERATION PERMIT
SYSTEM INSTALLED BY: : ��
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AUTHORIZATION NO����y�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'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACfORI[.Y FOR ANY GIVEN PERIOD OF TIME.
DCHD 07/02(ReviseA) � � � � �
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� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
�� APPLICATION FOR IMPROVEMENT PERMIT REPAIR
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NAME � � PHONE NUMBER ���`���� �.
ADDRESS '�' � ����L� ` /�-GI�'" SUBDIVISION NAME T�S � �
i��G�' v.���Y� `/ � �.� LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED � NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 'L�
TYPE WATER SUPPLY C_f� SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This ia to certify that the information provided is correet to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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