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Permittee�s � /
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� DAVIE COUNTY HEALTH DEPARTMENT
`% �r'.'/ Environmental Health Section
�� ��' � P.O. Box 848
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PROPERTY IIVFORMATION
Directions to property:l��'�i`d-� � t'l�i"»�d/r J�' Mocksville, NC 27028 Subdivision Name:
f " �"' '�'' � Phone #: 336-751-8760
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� ` , � / AUTHORI7,ATION FOR
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SYSTF,M CONSTRUCTION
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AUTHORIZATION NO: ��'� � A Road Name:
Lot:
Zip:
**NOT'E** 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 Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .] 900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
-"�%�y�✓ �..%�f ..�'`'�1 ,x`+r� �,i� i�i .�' ^._I ` �"'�/`� IS VALID FOR A PERIOD OF FIVE YEARS.
`ENVIRONMEN AL HEA TH SPECfALIST DATE ISSUED `
RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS �# BATHS �� # OCCUPANTS a' J GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF✓SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY ��ESIGN WASTEWATER FLOW (GPD) �� NEW SITE REPAIR SITE �,�'�'�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��ROCK DEPTH +{ �L NEAR FI'C��
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
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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 - 1:30 P.M. ON THE DAY OF [NSTALLATION. TELEPHONE # IS (336)751-8760.
I OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION N ��� OPERATION PERMIT BY: DATE•%
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**THE ISSUANCE OF THIS OPERATION PERMTT 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 SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
� ��=� � PHONE NUMBER / �� J� �/
ADDRESS ��� C`��G2 ��- �`-�' ' SUBDIVISION NAME
� / ` 0 G�� U ( / % -_'� �, %U� C� LOT #
DIRECTIONS TO SITE �o � [ .� �i i� ��-�'" ��-- � ���� `�
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DATE SYSTEM INSTALLED l � NAME SYSTEM INSTALLED UNDER �� ��� ��
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING N��� S ����,
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DATE REQUESTED �(�� ��INFORMATION TAKEN BY
This is to cartify that the intormation provided is conect to the best of my knowledge, and that 1 understand 1 nm r�sponaible }or all charges incurcsd from this applieation.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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