400 Griffith RdPermittee's DAVIE COUNTY HEALTH DEPARTMENT
Name: % f f' � r k. Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property:, -f' Mocksville, NC 27028 Subdivision Name:
.� "' �j ,., Phone #: 336-751-8760
Section:
AUTHORIZATION NO: ` � A
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name
Lot:
lam` Zip: 7-76R41
**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 I 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 ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOM # BATHS # OCCUPANTS /4(—" GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD}l NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �!ROCK DEPTH / LINEAR Fr. --2 J
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPI
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELERHggE #
��
<
OPERATION PERMIT
N
)1)
BY: /G
AUTHORIZATION NO.%:2—�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.
DOM 02/02 (Revised) / 7 ,
- oPermittee'sDAVIE COUNTY HEALTH DEPARTMENT
Name: Af ( Environmental Health Section PROPERTY INFORMATION
?�
P O Box 848
Directions to property Z Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
Air ASTEWATFR
AUTHORIZATION NO:
Lot:
SYSTF,M CONSTRUCTION Tax Office PIN:# - -
C �w E
<a A
Road Name l "'Er, I C Pj Zip: "t` ,I"
**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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r' f ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE —rr # 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 SUPPLY DESIGN WASTEWATER FLOW (GPD) ~-1 /r .1 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ~ROCK DEPTH`C L' LINEAR Fr.'--I--
OTHER
r.'--I-
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
�1 �/ r,
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPJ{O}� 9I'HIS SLEM�
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION EPHORE # IS (336)]if�j-8160.
OPERATION PERMIT
S:rAd; (,4
4,111A / k
AUTHORIZATION NO._�iOPERATION PERMIT BY: �'% DATE:49
**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 J— CC�./+� 6 `/ -7
//
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
NAME
LOT #
DATE SYSTEM INSTALLED /Py NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS---? NUMBER PEOPLE SERVED
TYPE WATER SUPPLY tLI df SPECIFY PROBLEM OCCURRING
DATE REQUESTEINFORMATION 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. 1193