454 Fred Lanier RdPermittee' __ C ' 1 D`AVIE COUNTY HEALTH DEPARTMENT
Name: k4 lky ``'= t f Environmental Health Section
A / P.O. Box 848
/fid -7-0/
PROPERTY INFORMATION
Directions to property: ! ` "" ! L) Mocksville, NC 27028 Subdivision Name:
i' Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: A Road Name: 1l `?" ¢ - Z1p �i-fit 3
**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 B�uildinc Permits.
(In compliance yvitt , icicle I I of G.$. Chaptw e ?gOA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONIYI$NTAL�HEfI'L' C{ SPECIAL IS f' D E SUE
RESIDENTIAL SPECIFICATION: BUILDING TYPE VICO - # BEDROOMS ';2:- # BATHS. # OCCUPANTS �._ 3 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPgqEn�CIFICATION: FACILITY TYPEE_ `. # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: -Yes/or No
LOT SIZE TYPE WATER SUPPLY — DESIGN WASTEWATER FLOW (GPD) O NEW SITE REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER t'"1Tt=1 los�%T�t r' i=c1X
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
f� r•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:
r`'t Imo-
66
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AUTHORIZATION NO. OPERATION PERMIT Y: DATE: )OLL
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T AT PSEM CRIBE OVE HAS BEEN INSTALLED IN COMPLIANCE
'vITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION.1900 "SEWAGE TREAPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GRANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
4evised1
X367
fwtovn4 t W -S 22/03
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) _
NAME � �Nj S PHONE NUMBER -Aps
ADDRESS j�'7L�� 1,A Iva PS SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED a_�o WAAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY__dSPECIFY PROBLEM OCCURRING ��'�(Gin�ly op.
DATE REQUESTED 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
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