682 Dulin Rdr.+'i..w°h..- �'" sr'n-`°--^-+v-.-r+ru �"�,.:.G�c"K^a«^v't-ti=j-(.��y�ty{;�,....•�:r-r^"r._,�.�,.;•��"C:J"vr�'+"--5.:.�fVw,,tyc.•..s;..:�++:.�i,'..y�F,...;-i....c..;�.,•-.,,....,;r. "i.�'�. 1 `:. Sd'Y •k
emit tCDAVYDEPA`RTMENT . ;
.Of
En
vir(inmental HealtFi'Section • _PROPERTY INFORMATION -
P O..Box 8481..
Directions to ro ert : 16 7 • ���^t
P P , y s Mocksville, NC 27028 Subdivision Name.
...3:e/ Phone # • 336-751-8760.'
'Section""Lot: • .
AUTHORIZATION, FOR
.WASTEWATER
�:. 'Tax Office PIN:#
AUTHORIZATION NO A Road Name:.f G. .i�!L1�%/� I{JZ��p/J:
**NOTE* *-This Authorization for Wastewater System Construction MUST BE ISSUED by the bavie County Environmental Health Section prior•
to issuance of any -Building Pernuts.",This F6mi/Auth6rization Number should be presented to the. Davie.County Building `Inspections -
Office when ap'llying for Buildm Permns.
(In comphanee with:Ar(icle I I of G.S. Chapter 130A W, ste.water Systems Section.. 1900 Sewage Treatment andbisposal Systems) ,
*NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
Jf'y �Ci/'• S IS VALID FOR A, PERIOD OF FIVE YEARS.:.
`"'ENVIRONMENTAL HEALTH SPELFI,ALIST D!NTE ISSUED
RESIDENTIAL SPECIFICATION BUILDING TYPE P/� # BEDROOMS # BATHS ' # OCCUPANTS GARBAGE DISPOSAL: Yes or No
i
COMMERCIAL SPECIFICATION: FACILI'TY TYPE .#'PEOPLE # PEOPLE/SHIFI' # SEATSINDUSTRIAL WASTE Yes or No,
LOT-SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEWSITE REPAIR SITE
t: •
SYSTEM SPECIFICATIONS: TANK SIZE'' GAL.:;,PUMP TANK. k GAL. TRENCH WIDTH, ROCK DEPTH �� LINEAR FT:
' OTHER � 1� I��• ��J11tDJ `' _ € �i
REQUIRED SITE MODIFICATIONISICONDITIONS;
mw
€:
'Upi
w
y
IN
red'..
yf
He
��R,D
s r
„ � e
m �
"
�• .$�. », : w -'�-� - '`��$..'� �'§ �� � ££� .. ��1. sc i'.x�
DAD
Guk
d
�6bE ' r 63 �.,
r r
00
tj
- Wa
I
IN
a
N
E
en
_. .
All" A
a
x
_
>
— max. •"'» ';u: � >' �
p
•:•11.E E.�.� / 3
•. 7 `
. t
r _
-
>
, ,.�.. rte. �;�. �--., a«:, ;. e'a="a:.• �� s-°,,.' L`!- � �',�,_ 'i ,•'$, » '� �"�
i
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) Q
NAME ` C_, � K� �� PHONE NUMBER ! ff - `r` F3 9'
ADDRESS �- u-� ' ✓ SUBDIVISION NAME
LOT #
DIRECTIONS TO S
N
I► Cr_o
C - S iZ;�
r
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDERti��
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING 7 �=A
I/ l�
DATE REQUESTED G 2 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge. and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
11^C-_ L 0, % 4 ,..