841 Cedar Creek Rd< - �7 oy
Permittee s�;�,,,., , �� DAVIE COUNTY HEALTH DEPARTMENT �� 7
Name: �r``,1 ` j�' �,`.�� �' �`'C��'�-%' i;�% Environmental Health Section P OPERTY INFORMATION
�' � P.O. Box 848
Directions to property �''� =� r' �. �" � -,..,' �; �qocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
% '�� ' /� �'�" Section: Lor.
�' � /�` ' � � � AUTHORIZATION FOR
1'�'ASTEWATF.R
SYSTF.M CONSTRUCTION
� �
AUTHORIZATION NO: � � � � A
Tax Office PIN:#
Road Name:
Zip:
**NO"TE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section pnor
to issuance of any Building Permits. This Form/Authonzation Number should be presented to the Davie County Building Inspections
Office when applying for Building Perrnits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r ' ***h'OTICE*** THIS AUTHORI7ATION FOR WASTEWATER CONSTRUCTION
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'� � ', : -`"> > : ; :%"', ' .r'� ; IS VALID FOR A PERIOD OF FIVE YEARS.
� ENVIRONIvIENTAL HEAC�'H SPECIAI.IST DAT� ISSUED '��
RESIDENTIAL SPECIFICATION: BUILDING TYPE r,� # BEllROOMS�� # BATHS ,- f# OCCUPANTS � GARBAGE DISPOSAL: Yes or No
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COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE TYPE WATER SUPPLY G�r'' / DESIGN WASTEWATER FLOW (GPD). �1-': �:� NEW SITE REPAIR SITE ��
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� �% ROCK DEPTH �� LINEAR FI'�-�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR I:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. ,
OPERATION PERMIT '� /�% i�/'
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AUTHORIZATION NO. ����� OPERATION PERMIT BY: DATE: � C7`� ���
**THE ISSUANCE OF THIS OPERATION 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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~ �e�,miittee's � ,,- DAVIE COUNTY HEALTH DEPARTMENT , �;, �
�� -Naiife: ° :�l � '��.� �` f - " Environmental Health Section P OPERTY INFORMATION
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Directions-to property: -" �'r ', , Mocksville, NC 27028 Subdivision Name:
� . Phone #: 336-751-8760
Section:
� . .. ' � AUTHORIZATION FOR
� ,, WASTEWATER Tax Office PIN:#_
SYSTF,M CONSTRUCTION -
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AUTHORIZATION NO: �'-� �+� � A Road Name:
_ Lot:
Zip:
**NOTE** This Authonzation for Wastewater System Construction MUST BE 1SSUED by the Davie County Environmental Heaith 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 Pemiit's.-
(ln compliance with Artide 11 of G.S. Chapter 130A, VJastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION ;
� - IS VALID FOR A PERIOD OF FIVE YEARS.
� ENVIRONMENTAL HEALI'H SPECIALIST DATE ISSUED
,...;.. _,.. . _
RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS � f`� # BATHS f 1 # OCCUPANTS ��� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE -� # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
�r } � . . � �rt �,
LOT SIZE TYPE WATER SUPPLY �%'� -�/'� f DESIGN WASTEWATER FLOW (GPD) t�;" f�� NEW SITE REPAIR SITE ��✓"�
�' �, r.�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCN WIDTH �-� �-' ' ROCK DEPTH � r LINEAR Fn- w� �� ,'
" OTHER
REQUIRED STI'E 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 # 1S (336)751-8760. -,
_ �._-.._�"�'
OPERATION PERMIT �� ^Y
SYSTEM_INSTALLE �-------'—' ���� I f�
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AUTHORIZATION NO. � 7 OPERATION PERMIT BY: �� DATE: ��( �`'� �(/ (
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"'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I OF G.S. CHAP'fER 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 (REPAI )�
� ���' �3 �S'
NAME ��- ��t c��- V' �-`r' ye/t PHONE NUMBER
ADDRESS U� � �'e_ c� a� �-re--e--K �'� . SUBDIVISION NAME
� D c- K S l� i l(� LOT #
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DIRECTIONS TO SITE � � g �,.,�a � Q c'� `�' � ��` �'�S �'`J
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a. ,r►�-LS � o �� — �`'a.. s �- C �.�-� �.1� . 3aY-� . C,4.
'V� %.�.f-+�- F/'a .r, � %'L� ..�re S-1 �-s b�Lc..lc �bo ...�!- 3 ao � �r...._ ro.c.t
DATE SYSTEM INSTALLED �'�' 8 9 NAME SYSTEM INSTALLED UNDER ������-•�- ���-n ��-� �-
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED %-
TYPE WATER SUPPLY ��- � � SPECIFY PROBLEM OCCURRING
DATE REQUESTED �' �-s �'� INFORMATION TAKEN BY �--
Thia is to certify that the intormation provided is correct to the best ot my knowledge, and that I understand I am responsible lor all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93