587 Bolt Rd , . , . , .
'Permittee's�� l DAVIE COUNTY HEALTH DEPARTMENT �� � '� � �
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• �.?Yame: • ��=�/'�P��{ ;'��r.a r} /`''.-�'/' Environmental Health Section PROPERTY INFORMATION �'�`�
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Directions to pmperty:_.�f's e'` %��'f�-�" -' � Mocksville,NC 27028 Subdivision Name: � 1 OOC�� I � �
' ; �.� � Phone#: 336-751-8760
�/r"r'�t�.���'f' .,� r,1` �V Section: Lot:
��`•~ AUTHORI7.ATION FOK �$�t /�`Cl
WASTEWATF.R Tax Office PIN:# - � � - _` D�
�} D� �� 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 pnor
to issuance of any Building Permifs.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)
.� ` � q, �.! �°.. ,�r,� ,� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� � .. ',.,r i :� �. ''�t !r".♦ N'�,� "" i�� � -� r , r^"
r,, t� , >� �..x; t r'"�,� j _ � ! .,i ; ��,,, IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTA SPECIALIST DATE 1SSUED '
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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 C_.71 DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE &"
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH--�L<% ROCK DEPTH � /LINEAR F'I�'�lf�
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 8:30-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF[NSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT �� ,) r �
SYSTEM INSTALLED BY: -�''1�N'f 1^'M�T��R
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AUTHORIZATION N�I(Y�� OPERATION PERMIT BY: DATE: � �� � l
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTE CRIBED ABOVE EN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 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.
DQiD 0?J02(Revised) � - .
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� ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �
. ^ APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
fJ �
NAME �Sr S� Z��- PHONE NUMBER �
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ADDRESS__ S fS 7 �e+��' • /�-� • SUBDIVISION NAME �
� ` LOT # �
DIRECTIONS TO SITE �'
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DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �^
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DATE REQUESTED INFORMATION TAKEN BY �,
Thia 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. �
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SIGNATURE OF OWNER OR AUTHORIZED AGENT �
Rev.1/93 v
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