664 Howardtown Rd .,Permit tee's DAVIE COUNTY HEAL
.•, TH DEPARTMENT �°�
Name: `�C-J ' � a /�/��%'�'t Environmental Health Section PROPERTY INFORMATION
',' P.O. Box 848
' Directions toproperty:. r'l / �'�" �'�f ''�' "��' r
`� Mocksville,NC 27028 Subdivision Name:
f/•�.i'y-k ; a , �(/ �'` Phone#:336-751-8760 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002589 A Road Name: Zip:
**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 Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In co m p11 ante with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
1
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE It #BEDROOMS .9-- #BATHS—Q--#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE// #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes
soorrNNo
LOT SIZE TYPE WATER SUPPLY //DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE Y
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `S ROCK DEPTH 'LINEAR FTS' dd
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT -
SYSTEM INSTALLED BY: I d'is /ZIP
�w a�
jI
AUTHORIZATION NOL 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.
nclru mioz(Revised) Qe-� (2
r*Permittee's� /�� ,, �„ � DAVIE COUNTY HEALTH DEPARTMENT .3?"Name:" `�' �'if-^r"f .Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to-property: Mocksv•Ile,NC 27028 Subdivision Name:
Jr Phone#: 6-751-8760
�^ c Section: Lot:
AUTHO ZATION FOR
WAS EWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002589 A Road Name: Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Count;G`Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office wherYapplying for Building Permits. /. i
(In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage 1`reatment and Disposal Systems)
1
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE Jf #BEDROOMS #BATHS__'2—#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPEr / #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No esorNo
LOT SIZE TYPE WATER SUPPLY fi✓t° /DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
I
/ �'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT/d d
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
t
t
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
U
AUTHORIZATION NO.6'�OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
.WITH ARTICLE I I 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.
ncrrD ozroz(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME
7�-C�L_r'Sl
� � �� PHONE NUMBER
ADDRESS� ��Li�lG I 'v , UBDIVISION NAME
LOT #
r
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER SPLE SERVED
TYPE WATER SUPPLY 2z SPECIFY PROBLEM OCCURRING ' lhua
DATE REQUESTED S 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.1193