1273 Calahaln Rd_ , .
,"' Pernut<;e's , ,;-j DAVIE COUNTY HEALTH DEPARTMENT `��'� ' dcS�
• Name: .�-+'-�_'�-+1.' �' "=•'i�•i�G�'i Environmental Health Section PRO ERTY INFORMAT ON
' '' J '� P.O. Box 848
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Directions to property> � F' �t E�~-. f' /.' %:;> :r ,;' x��' �,qocksville, NC 27028 Subdivision Name:
�,,�:� ; '` i:`f :�i. ;; ,' �: Phone #: 336-751-8760
,,. t �. --• � Section: Lot:
, � � �AUTHORI7.ATION FOR
�lA,� l, , � ,!', r ry �,.' f�, �,! ;,j'"c� ��''� f WASTEWATER - -
f "'�`� �'� ' " r � � �'�+ `�SYSTF,M CONSTRUCTION Tax Office PIN:#
--AUTHORIZATION NO: �,�; �a �� 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 Pecmits. 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)
' /�,.,� ; :-�' ., ` „� ,�•" �, ,/ ***NOTICE*** TH1S AUTHORI7ATION FOR WASTEWATER CONSTRUCTION
�� � ii:' '�i ��-,�rr f r;d. �,'�� �.,�,r.��':�1'�� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DfATE ISSUED
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RESIDENTIAL SPECIFICATION: BUILDING TYPE �� # BEUROOMS �-�-� # BATHS =�� �.�' # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
�. �
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE TYPE WATER SUPPLY ���? _ DESIGN WASTEWATER FLOW (GPD) /� NEW SITE REPAIR SITE ��''~~ � l
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH � r� I ROCK DEPTH � LINEAR FT. �'�� %�
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 - 130 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION NO� OPERATION PERMIT BY: DATE: �� �� �
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"+THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYST M DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
DCHD 01J02 (Revised)
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NAME 'e�
ADDRESS �
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DIRECTIONS TO SITE_�
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER� ��'-' ���5
�( SUBDIVISION NAME
LO� #
� ��' ��' ��
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE S RVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING - } iI'
DATE REQUESTED �� INFORMATION TAI�EN BY
This is to certify that the information provided is correct to the best of my knowledge, �nd t�at I un n I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1/93