584 Martin Luther King Junior Rd�-. r-t�- f�''�-�-i—
� Pecmiitee's � f. �. �% DAVIE COUNTY HEALTH DEPARTMENT
.. Namei ���'r°/ %`,%' -�' f•�.�-� ��°`1 x`j �` f' Environmental Health Section
'� � �� + P.O. Box 848
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� Directions to property. 1�^f'4 � r a: t�' �',�:�� Mocksville, NC 27028 Subdivision Name:
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�,M��r�,r�� .«♦ �; �;� „��" ' Phone #: 336-751-8760
' Section:
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` �AUTHO�RIZATI N NO: � �� �` �
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PROPERTY INFORMATION
Lot:
Zip:_
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Perniits. This Forni/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r' � p,J -„�;-^`"-"iti, - %�' -- ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
. p`�i.�l' t'�• f` r T�`.,�.�r,:=, -`tT�� �.,�1�` IS VALID FOR A PERIOD OF FIVE YEARS. ,
:NV�RONMENTAL HEALTH SPECIALIST DATE 1SSUED
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RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS f�+`� # BATHS c�� # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY�' DESIGN WASTEWATER FLOW (GPD) ��" NEW SITE REPAIR SITE ��
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTI-� r^� ROCK DEPTH�_ LINEAR Ff.
REQUIRED SITE MODIFICATIONS/CONDITIONS: _
IMPROVEMENT PERMIT LAYOUT
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"`*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY ALT EPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE D Y OF [ TALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEMINSTALLE BY: _ �%/J%��(/ Gt�r% /�I
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AUTHORIZATION Tf�x%�S� OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIA CE
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.
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���'Pernuitee's • � ,� DAVIE COUNTY HEALTH DEPARTMENT
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��-� r _ • �, .�r � ; P.O. Box 848
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PROPERTY INFORMATION
._•-"Direcdons to property; � ;�" � f-' Mocksville, NC 27028 Subdivision Name:
' r'f ' - Phone #: 336-751-8760
f �'�• ; ;,;��'' Section:
' � AUT�-IORIZATION FOR
% ,-' •�'�f' ; •, t�, ¢��,, ,�f , `;, ,',, ',�yVASTEWATER Tax Office PIN:#
` � SXSTF.M CONSTRUCTION —
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"AUTHORIZATI�N NO:4� +�. �'�r` � p Road Name:
Lot:
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 Form/Authorization Number should be presented to the Davie Counry 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*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
'� r t r'� ;..' ; �� � -=,` � `�� ;' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED �
r�:
RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS �# BATHS c�'� # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE TYPE WATER SUPPLY ��°'�'i` DESIGN WASTEWATER FLOW (GPD) �'� r{� NEW SITE REPAIR SITE �'"`�
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH_t t.. - ROCK DEPTH �'�✓'f ` r�LINEAR FT. "`
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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**CONTACT A"REPRESENT�jTIVE OF THE DAVIE COUNTY'f�
BETWE�N 8:30 �_930 A:M. OR 1:00,;— T`.3QP.M. ON THE
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LT EPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
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OPERATION PERMIT
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AUTH�RIZATI�N N� )ATE:
••THE ISSUANCE OF THIS OPERATTON PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN 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.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
QJC� --- �/'�Co,�'� 1�'�S� �HONE NUMBER �<� �� ( '`"
ADDRESS s� �� C�""� ��-�� �- SUBDIVISION NAME
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DIRECTIONS TO SITE �'% l�F C- C( ��,!-r 2 c(y �"�^' ���
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DATE SYSTEM INSTALLED ? � NAME SYSTEM INSTALLED UNDER '
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SEFi`VED
'�-� -e � � SPECIFY PROBLEM OCCURRING `�� � �� ��f
TYPE WATER SUPPLY �_�
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DATE REQUESTED � � INFORMATION TAKEN BY_,�Q
This is to certify that the information provided is correct to the best of my knowiedge, and that I understand I am responsible for all charges incurred }rom this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1 /93
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