116 Elk LnPermittee's i AVIE C .LINTY HEALTH DEPARTMENT
Narne: - ' } i lit tl:nvironmental Health Section. PROPERTY fNFORMATION
A) P.O. Box 848,.
Directions to property:y-) VL1. Mocksville, NC 27028 Subdivision Name:
'i n
rl �^- r t Phone #: 336-751-8760
- t' , �.1 i C LZC L./� Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION NO: A . ' Road Name:
��� Ce~ Z Zip: c't`IL�
**NOTE** 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. -
(ln compliance with Article;I l of G.S> Chapter 130A,,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
LVIIFONM NTAD TH SPECI, IF IST DAT ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE �-4;# BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE � � '"" TYPE WATER SUPPLYf DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE -----GAL. PUMP TANK GAL. TRENCH WIDTH �P ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: N "10001
**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 . ` n
SYSTEM INSTALLED BY: W1Lt4 AA,.— Lir r
x w. L wa FoO
-ice . ✓/4/
�► � �E
AUTHORIZATION NO. ��- OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDIAT HE Af�M DESC DAO HA BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREAT AND DISPOSAL SYS MS", T SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF Tl
l._
02102 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT C� �'�•-.
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028, -
Phone: (336)751-8760 ENVI 0
NMErITAL HEALTH
DAVIE cou
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: �� Ci^w� Phone Number: ��� `` `s Z (Home)
Mailing Address: 2'y / 14 l-, 57t V%-3 t3 (Work)
ywo c..l�S ✓ � /k.. N �—
Detailed Directions To Site:
o /e -
P /h a
Property Address: F, L. %a,, � L--e,e /r e —
Please Fill In The Following Information About The Existing Dwelling.
34,
Name System Installed Under: scARJ 13 La -c �w�� D Type Of Dwelling:10
�''��
Date System Installed(Month/Day/Year)' *i 9 go' 5 Number Of Bedrooms,--2--Number Of People:
�
Is The Dwelling Currently Vacant? Yes �""No ❑ If Yes, For How Long?
Any Known Problems? Yes ❑ No 13/ff Yes, Explain:
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling: h 0 Number Of Bedrooms: Number Of People:
Requested B c X d ��L...�Date Requested:�?� Z
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
C'nmmPntc- (� `^`(nL -7)24,)02—
Environmental
)` 'Y)0Z
Environmental Health
I*The signing of this form by the Environmental Health Staff is in no waMtended, nor should be taken as a
guarantee(extended o_t limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Cf Check ❑ Money Order ❑ # A t: I
Paid By: C Received By:=
Account #: 2— -<,? D Invoice #: M
le–_ o
t�`" S .�!�`; -•`,� + a v .a, .0 fir;, $ ,- ,tet r - * fy„t';{, +.^'ro r '
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO-Box 848/210 Hospital Street
'Mocksville,NC 27028
� w
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
( ) ❑ RECONNECTION ❑
Check One REPLACEMENT❑ REMODELING
Name: P iPt-n/J, �,,� 'amu' Phone Number: (Home)
' Mailing Address: -?-0 7 73-- D (Work)
y1n /�S✓ 1 i� C-~
Detailed'Directions To Site:
Property Address: '� U Wit- o
t
Please',Fill In The Following Information About The Existing Dwelling: .�� `
Name System Installed Under: 0 SCAR l a.t- r-, e Ld Type Of Dwelling:
',Date System Installed(Month/Day/Year): 1 7 80' S Number Of Bedrooms: Q Number Of People:
IS The Dwelling Currently Vacant? Yes 4 No If Yes,For How Long?
'AnyKnown Problems?Yes❑ No Yes,Explain:
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling: Number Of Bedrooms:.
/f Number Of People: — a
Requested B L Date Requested: Z---
(S gnature) >.u.
For Environme ''ta[ Health` f Use Only
Approved ❑ 'Disap roved ❑
Comments: ' Q � `^" `i .s J,�D 2u DZ
1 Environmental Health Specialist i (Date /
*The signing of this form by the Environmental Health Staff is m� nqnded,nor should betaken as a
guarantee(extended or limited)that the on-site wastewater system fi�inction propgrly for any given period of time. ,
Payment- Cash tT<heck❑ Money Order❑ # r t�-�'S'o a Date: r%"d-
Paid By: C Received By-,--""
g {
Account #: Invoice #:
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