131 Frank Short RdPenaitiee's / DAVIE COUNTY HEALTH DEPARTMENT
Name:ori ?_ '�' / Environmental Health Section
..PJO. Box 848
Directions to property:•'' 1`1dcks'�ville,; NC 27028
Phone #: 336-751-8760
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 2 13 9-1 A
PROPERTY INFORMATION
Subdivision Name:
Section:
Lot:
Tax Office PIN:# - -- ——
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 with Article l 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.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISS ED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS '`d�� # BATHS # OCCUPANTS W GARBAGE DISPOSAL: Yes or No
1
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL? TRENCH WIDTH !; `6 ROCK DEPTH LINEAR
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
t
**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:
S
AUTHORIZATION NO. �/ I OPERATION PERMIT BY: DATE: '
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
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Pei:nif�ee's , ,; t DAVIE COUNTY HEALTH DEPARTMENT'C v `S
rTame �.�"• r; .;. `, Environmental Health Section ' PROPERTY INFORMATION
P.O. Box 848
Directions to property: <11-�4 Mdck ville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
f , r Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#_ - -
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 with Article I 1 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.
ENVIRONMENTAL, HEALTH SPECIALIST � DATE ISS , E �
D
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS '47 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
`t
fe
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY / DESIGN WASTEWATER FLOW (GPD) `'. - /NEW SITE i REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL: TRENCH WIDTH . ROCK DEPTH LINEAR FT:•'%''�(—
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT ti,--�-^"^�---. •---�.
**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:
AUTHORIZATION NO. OPERATION PERMIT BY: 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. 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 02/02 (Revised) 1
R
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPL CATION FO IMPROVEMENT PE MIT IR
Y,,
�' �' PHONE NUMBER /*)- (/3�-?
r
' ��LZI�I��/�r/lam Ew, r -SUBDIVISION
DATE SYSTEM INSTALLED�&q-
NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 74' NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED _T1 LL 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
FFjOWNER OR AUTHORIZED AGENT
Rev. 1ry3