190 Essic RdPerrnittee's DAVIE COUNTY HEALTH DEPARTMEt�
Narne: j � y�6 } �~� Environmental Health Section PROPEERR, T NF RM I N
t-� " `- 7�� P.O. Box 848 Ci1'2"� -0
Directions to property:_} t_ Mocksville, NC 2702E Subdivision Name:
} (� .y , Phone #: 336-751-8760
At'
t . I (. ` ( �' .. } Q1 Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION17 Tax Office PIN:#
(30
AUTHORIZATION NO: '�� A Road Name: "'�'" Zip:
**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.
(In compliance wilh,Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f h ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.5 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONONTA _11 AL' 14 SPECIALIST "+ DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE . Ho09# BEDROOMS --:S—# BATHS # OCCUPANTS ^' GARBAGE DISPOSAL: Yes or No
COMMERCIrAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE` `�4- E WATER SUPPLY t',/� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCHWIDTH— ROCK DEPTH �L LINEAR FT..
15
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
�I
IMPROVEMENT PERMIT LAYOUT
IJ
ts.
Q J
T
12
pJ �-ij -Tea i d T AJ 1
"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:
J
1
L-
-1
_A
AUTHORIZATION NO.'^OPERATION PERMIT
L
IS
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT fHE kk1iFDEkkiBED ABOV
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSM
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
:DATE:
EN INSTALLED IN COMPL ANCE
SHALL IN NO WAY BE TAKEN AS A
DCHD 02/02 (Revised)
c� J"
l
of ✓ `C& Vv
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) �j q
�f PHONE NUMBER 77
ADDRESS '10
S /•c.
A ' SUBDIVISION NAME
Ctles ✓
�i' LOT#
DIRECTIONS TO SITE
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(A) a N )."� &��-
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a � � . C�� �j�..'F-rL,�.lt,•�-rte
't-^�.i'1 � ,��
DATE SYSTEM INSTALLED
73
NAME SYSTEM INSTALLED UNDER
TYPE FACILITY
NUMBER
BEDROOMS NUMBER PEOPLE
SERVED /
TYPE WATER SUPPLY_Wal..---SPECIFY
PROBLEM OCCURRING14
V
DATE REQUESTED / x"7--0 3 INFORMATION TAKEN BY,
This is to certify that the information provided is correct to the best of my knc
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
incurred from this application.