1393 Cornatzer Rd (2),'�"' _ . . . � 2//���
Permittee's��/ �/� ,�� DAVIE COUNTY HEALTH DEPARTMENT
Name: (;r`� %�� � ri���`i f" Environmental Health Section PRO RTY INFORMATION
► . � """�. P.O. Box 848 .
Directions to property;�!` ✓� f�,..'>�� t•'�'rs� �% /`",si`� Mocksville NC 27028 Subdivision Name:
,�-�� °,! • ,,�„ t'' s.,:J ,r'�iY , `..S"f:� Phone #: 336-751-8760
,`� C��1 �r.:'�l7f'� �-�if�� -' �� Section: Lot:
} AUTHORIZATION FOR
"r'; ' j'1P ' ;f,�;+� r' �t,�`,,1.�° 1'../�./'� WASTEWATER
���' � SYSTF,M CONSTRUCTION Tax Office PIN:# -
AUTHORIZATION NO: �'"t � r� �" A Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
ro issuance of any Building Permits. This Fo►m/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)
i
'' ��.�/' w✓� � ,.-^' ,„ ,Fi /r.•' "�f r -,:- ***NOTICE*** THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
� ,I L;:..�,f ,�, r,d. �,� ,i� r,:x f/° _'+,1 "` ; ✓
�/.� �% �• O'< �,t.F.,!-✓ �+ ,�_ �- - e._ •= �"4 z.--� IS VALID FOR A PERIOD OF E'IVE YEARS.
ENVIRONMENTAL EALTH SPECfALIST DATE 1SSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE /�� # BEDROOMS�,� # BATHS _
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFf
# OCCUPANTS � GARBAGE DISPOSAL: Yes or No
# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
�j /i r �,.1 s � �y
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� `�% ROCK DEPTH '��� LINEAR FC"'��c„ �!�
OTHER_!!�11 � �C I_�C! IV�/J% /r,j:�/'�%/` J '�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
•� ��,�' ��
C! � ''' � �"'`�-�.
� , � ..� �
. ° �-� J,..�„_._.._..,._...:
, � � � , �..��-._.---
vS �1`��
� �
�yl� �
�rn ����
,-� , ���
��°
�_
**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.
I OPERATION PERMIT
SYSTEM INSTALLED BY: �� � �• � � �l �C.� �.��` �C���
� �
4
5 .
�
�
\ �
R��� 1 ��� ,�
I v�
0� I
1
AUTHORIZATION NO�� OPERATION PERMIT BY: !'�'�^'`--� DATE: `—�� d�
•"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS SCRIBED 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.
DCHD 0�/02 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
� - APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) 33 G-� ��• �� y�'
� / l e�Ct 13 s
NAME_ �/1 �c S /� ��7`c� n� PHONE NUMBER �.
�
ADDRESS � � � 3 CO (' ►�.�-Z.e.,e /2�( . SUBDIVISION NAME q 7 � �Y� /
�'?�. o��S ✓� � I t_ LOT #
DIRECTIONS TO SITE �" c L_( .✓`.. 12.c -
�,
� �--� 1-�--�.-� �
,tvx. �..-
(
�� � �
- � , .
DATE SYSTEM INSTALLED t�a ��� NAME SYSTEM INSTALLED UNDER Tja n✓�.c �-�- ���-� �f
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING S-��I'�'�c_ ����.+ c�
-T
DATE REQUESTED � ��. INFORMATION TAKEN BY____1'�k�-� -r-;-a---�-Q p
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible }or all charges incurred from this appiication.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93