146 Howell RdDavie County Health Department
his t� Environmental Health Section
+ P.O. Box 848
C�
,S, 210 Hospital Street
Courier # : 09-40-06 1911
t Mocksville, NC 27028
Phone: (336) - 753 -.6780 ON-SITE WASTEWATER CERTIFICA Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
Name: h �L f `j-� PhoneNumber C� - - g (Home)
Mailing Address:_q ({' , tl-o do t. r+r /eck �� (Work)
y\oC�sVil I e I Email Address:
Detailed Directions To Site: o o C, -)_LC) rN S olhu v ck:: U —
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Property Address: I �Lu 00W t
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility: AkIA11 Q�
Date System Installed (Month/Date/Year): Number Of Bedrooms: ca Number Of People: 02
Is The Facility Currently Vacant. Ye No If Yes, For How Long?
Any Known Problems? Yes (Z) If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: :L( 60 _�u i Gt n _ Number Of Bedrooms: C Number of People
Pool Size: Garage Size: �� Other:
Requested Ery. nt 1 A__V Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved isapproved
merits: 1?i �` 0_0L`,Sc •C%yl i
Environmental Health Specialist._Pate:��
*The signing of this form by the Environmental Health Staffo in no way,intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Che Money Order # 9 Amount:$ 100. UO Date:
Paid By: 1) 4, 4e 0 u� ' b. P �- Received By: . ' b G
Account #: Invoice #:
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_ ~ O TTxRIZAT0N_NDAVIE COUN
=* Environmental Health Section ' PROPERTY.INFOi�1VIATION
Permitt_ee's P.O..Box 848' '
Name Mocksville,NC 27028 Subdivision Name
' - Phone# 336-751-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR ,
WASTEWATER _
C_7 Tax ffj PIN#
SYSTEM CONSTRUCTION L.�r '
r
v rvtiJc�� G�-.'� � ' �.!►� �-J` Road Name: ut y;u: k `' Ztp:. .
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any,Building-Permit..This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.,
(In compliance with Article 11 of G.S.Chapter.130A,.Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
IS AUTHORIZATION FOR WASTEWATER{ ***NOTICE***THIS
IS VALID FOR A PERIOD OF FIVE YEARS CO
ENVI O "E AL-HEALTH�SPECIALIST' DA E ISSUED '
DCHD 05/96 (Revised)
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;41!4e/tr WTI -Int ur:►` MO --a4- SAG/ L:
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME &9,,w G°�1a>r il�yn✓i 4A, 9�Yp-3773 PHONE NUMBER X42 -7/6 7 -
ADDRESS
ADDRESS / 4t? Iowa l /e /99o4ed&-Ik M 77d4f"' SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE % A41 e'� A/• -r. Ger1 �a�rr// , - /V•f•>i/'li 4w:24
Yv% P_b
DATE SYSTEM INSTALLED /? 7/ NAME SYSTEM INSTALLED UNDERLY://%41,•s Nr.L's
TYPE FACILITY M_ NUMBER BEDROOMS .2- NUMBER PEOPLE SERVED
TYPE WATER SUPPLY k9ff SPECIFY PROBLEM OCCURRING L`1A"-
i'Ce_ l2a�l
DATE REQUESTED lav 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