180 Hunt St (2)`ttees `"` _ DAVIE COUNTY HEALTH DEPARTMENT
Pe*mi
Name: ...w '>''� Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO:' 2 3 l A Road Name:AV(,' Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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 fo rBuilding Permits.
(Incompliance with, Article -1,I of S. CiT5"pT6rr MO0 , Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
Tf U ? IS VALID FOR A PERIOD OF FIVE YEARS.
�ENVM NN "'H
A EAT;tff1 SPECIALIST l DA' E IS UED
RESIDENTIAL SPECIFICATION: BUILDING TYPE - -# BEDROOMS #BATHS ' #OCCUPANTS ' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT ry # 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 ROCK DEPTH z' LINEAR FT.
OTHER I) 1 k-1'CtoJD9C-
REQUIRED SITE MODIFICATIONS/CONDITIONS:P
**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 1
SYSTEM INSTALLED BY: 4
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2 Q
AUTHORIZATION NO. ` OPERATION PERMIT BY: DATE: Wo�
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVEA EEN 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.
MHD 02M (Revised)
DAVIE COUNTY HEALTH DEPARTMENT 1 rj` f
-Name: � =, , - ' Y� Environmental -health Sectiori PROPERTY INFORMATION
P.O. Box 848
Directions to property: '+ =^'I ? Mocksville, NC 27028 Subdivision Name:
r Phone #•
r,
('a', i t .336-751-876 '
, " Section: Lot:
AUTHORIZATION FOR
M WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: A Road Name: 5,`f °, }' " Zip: r Lill""
**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/AuthorizationNumber should be presented to the Davie County Building Inspections r
Office when applying for -Building Permits.
(In compliance with Article I I of GIS. C e OA,'Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
M ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
T
IS VALID FOR A PERIOD OF FIVE YEARS.
'ENVIRONMENT�C "HEACTIISPECIALIST DATE IS UED
RESIDENTIAL SPECIFICATION: BUILDING TYPE �� # BEDROOMS # BATHS # OCCUPANTS ^'�" GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
All
, �+
LOT SIZE `'" " TYPE WATER SUPPLY (A f k DESIGN WASTEWATER FLOW (GPDj ��"� NEW SITE REPAIR SITE
SYSTEMSPECIFICATIONS:
SPECIFICATIONS:.TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH i � LINEAR FT.
r _ ,
OTHER ti F;. i F+4J'�► tC `3i..
JT
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M.OR ':007 i:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
1?'t
\5
Df
$7 -1;J h _
'77
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: _
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABLEEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 0= (Pevised)
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1
is 4.,.$ 4- r L4 -c- i -t a .j d ti A-� iN
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME C.m ! cr&.t-;r"Lr PHONE NUMBER 7 Z3—se QJ
ADDRESS �d S T" A-�-3 SUBDIVISION NAME
o C' J t l l ,c. LOT #
DIRECTIONS TO SITE ';tr St S D &A— SIA -IJ T1
DATE SYSTEM INSTALLED KN • w NAME SYSTEM INSTALLED UNDER
- J ;'34-k Z
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED �--
TYPE WATER SUPPLY C �'�= SPECIFY PROBLEM OCCURRING4-�-�-
7 0 � h ► .rl..� �...q.,lL t ti o �..�" '� l a o 1 � '�--'.r" '�'_�- . (O r't� ,%j / t r -
DATE REQUESTEINFORMATION TAKEN BY.D
This is to certify that the information provided is correct to the best of my knowledge, and that 1 understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. if93
'_: o 5-7i/g- 0,c- 5 G 3 /