120 Grubb Rd• PeYrxtictce's I� D VIE COUNTY HEALTH DEPARTMENT
Name: A..Environmental Health Section
P.O. Box 848
PROPERTY INFORMATION
Directions to property: '� �-� ��' .'71 �� �� � Mocksville, NC 27028 Subdivision Name:
._ f 1-.� ?1.A' ,^j ( �.� Phone #: 336-751-8760
r� Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO:
Road Name:
} -zip:
**NOTE**
**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 of G.S-Chldpte 30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
/% �.-- �'' " j .-•� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
—ENVIjt NMFEN. 144EE"A`LT SPECIALIST. DAT ISS ED
RESIDENTIAL SPECIFICATION: BU(IILLDING TYPE # BEDROOMS # BATHS �_ # OCCUPANTS ? GARBAGE DISPOSAL: Yes or No
COMMERCIIAAL SSP(ECIFICATION: 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 1COOGAL. PUMP TANK GAL. TRENCH WIDTH ` , L� ROCK DEPTH + LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:'
IMPROVEMENT PERMIT LAYOUT
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0
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**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.
I OPERATION PERMIT
bA-r, t2-lZ
► to
SYSTEM INSTALLED BY:
4 �v -;4, 1XII
AUTHORIZATION NO. /ArA- OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEWDESCRIBED 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.
DCHD 02/02 (Revised)
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' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE ATC
Davie County Health Department
EnvironmentaiHeaith section APR - 4 2005
P.O. Box 848/210 Hospital Street
/ Mocksville, NC 27028
(336) 751-8760 EPNIRON&IENTALHE"
DAME COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed �_ t i✓(C Nr u.i C ci e1J Contact Person ` [ r L%
c)
l
Mailing AddressD /��/ Home Phone
(�-
City/State/ZIP Q C Sy+ l (' Business
,Phhone
2. Name on Permit/ATC if Different than Above '4
Mailing Address \\E3City/State/Zip
3. Application For: 13om
Site Evaluation J�l�l Improvement Permit/ATC Both
4. System to service: House 13 Mobile Home 11 Business ❑ Industry ❑ Other
S. Type system requested: l] Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms # Bathrooms
❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
8. Type of water supply: ❑ County/City Well 1:1 Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1 No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
Tax Office PIN: # 1574 &)' 0 0 - ,��^^ o L -L,/
Property Address: Road Name /,P-0 (7/"u ii',r, L2 --f,
City/Zip
If in a Subdivision provide information, as follows:
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Name: 5_f -.'J
Section: Block: Lot: 6 't I
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
E 2 .�
C / fJ3.
Date home corners flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. 1, also, understand that I am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owne -by
to conduct all testing procedures as necessary to determine the site suitabi ty1
DATE L_/ _ � SIGNATURE Z'J
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all lie following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
�0 C���
Sign given
Revised DCHD (05/03
Account No. -. j: , O
Invoice No. 1/75�
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