293 Davie Academy Rdw- ;. j _.., _ PQ 11-lS o�
►'' Permittee's�"; _,. �' ',- DAVIE COUNTY HEALTH DEPARTMENT
Name: - �%�-F �-^-�- %%�`-� � r Environmental Health Section PROPERTY INFORMATION
� t.. -,�r. f � P.O. Box 848
Directions to property: 1_ c•�= �' �'�' �' C F� Mocksvilie, NC 27028 Subdivision Name:
� � "�� c'`�l': ,�� ,'' !�c' -' L:.; Phone #: 336-751-8760
-� ��� • Section: Lot:
`�'' AUTHORIZATION FOR
f � < <,, �,v, r:>��; , , .,•` •^ `� �,-;.5 �,; I" WASTEWATER Tax Office PIN:# - -
� SYSTF,M CONSTRUCTION
i"� �a �'' `' , � �,,;�;`. !:
AUTHORIZATION NO: � � t-� A Road Name: Zip:
**NOTE** This Autharization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. 7'his 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*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� .' , .
;,*'; �' .;='--,t ,�':: }✓� '���j:�' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS �_ # BATHS �# OCCUPANTS � GARBAGE DISPOSAL: Yes or No
6
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY �%c./� DESIGN WASTEWATER FLOW (GPD)!,: "l�/� NEW SITE REPAIR SITE ��✓�
f d ,, ..
SYSTEM SPECIFICATIONS: TANK SIZE �GAL. PUMP TANK GAL. TRENCH WIDTH�-��� ROCK DEPTH � LINEAR FT �fT�*''
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
�' c
r
�
�
**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 INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
�
c,.
r,
��/,� �
AUTHORIZATION NO. � OrERATION ?ERMIT EY: DATE:
""THE ISSUANCE OF THIS OPERATION PERMIT 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.
ncHn o�noz c���5�
�
33 � �
��,/`� ���D
v
�
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
�I c-c- y�S �'^ �Za-���'�'v PHONE NUMBER 7 � � � �� � �
ADDRESS �—q �3 1�a-J� �- ��-�'��f ��' SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE ��tn ���J � `t-+' S-4-a ,� S sc .J LT� v^� D� J� e-
�- Lo� � � v�--x-- �f' -Q-- r.-. � �' t� a o��'"� �, u-S �
DATE SYSTEM INSTALLED �°� � NAME SYSTEM INSTALLED UNDER � a�� �"��'�
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED I
TYPE WATER SUPPLY J���SPECIFY PROBLEM OCCURRING L-1 +� �s ^�ac �`�"
- � !�_. � r.-,if-S a /�
�--�./1lL �L,S �
DATE REQUESTED �l L O INFORMATION TAKEN BY �
This is to wrtify that tho informa0on provided is eorcsd to the best of my knowledpe, and that 1 undaraWnd I am rasponsible for all charpes incurrsd from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93