428 Greenhill Rd (2) } L: 't \ " v.. .._ Y'-� r • , , 1., - r _ � i . a v�. .c,�..,,... — . i•.-: r '.
'\lmittee's }� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
° - /V ,r r P.O:Box 848
Directions to propert}: Mocksville,NC 27028 Subdivision Name:
Phone#:336-75178760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Office
SYSTEM CONSTRUCTION Tax PIN:# - -
AUTHORIZATION NO: ;0 4 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 Form/Authorization Number should be presented to the Davie.County Building Inspections
Office when applying for Building Permits.
(In co pliance with Article 11 of G.S.Chapter 13,0A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
of 'r or r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION'
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMEN AL HEALT -SPECIAIISY DATE ISSUED
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
LOT SIZE TYPE WATER SUPPLY.6 DESIGN WASTEWATER FLOW(GPD) !fL NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK. GAL. TRENCH WIDTH ROCK DEPTH LINEAR FJ
OTHER
�s }f
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
LACT 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 /
�••► A- �B4FEM INSTALLED BY: L C�
AUTHORIZATION N0. OPERATION PERMIT BY: G� 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.
DCHD 01102(Revised)
Z-'7(-7V9
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
/ APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) c
NAME PHONE NUMBER t
ADDRESS 7�-�S ��/^ e SUBDIVISION NAME
LOT#
DIRE IONS TO SITE
T z a- '
DATE SYSTEM INSTALLED 5 S NAME SYSTEM INSTALLED UNDER—
TYPE FACILITY NUMBER BEDROOMS r NUMBER PEOPLE SERVED
TYPE WATER SUPPLY( ':OU� � SPECIFY PROBLEM OCCURRING cep oa .t,-.dam.
DATE REQUESTED ) INFORMATION TAKEN BY 0Y
This is to certify that the information provided is correct to the best of my knowledg ,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT Til vt. .
Rev.1/93
Davie County Health Department
Environmental Health Section Payment Due Now.
PO Box 848 (210 Hospital Street) Please Return a Copy of the Bill with Payment.
Mocksville, NC 27028 Your Check is Your Receipt.
(336)751-8760
Harry Massey Account No: 990003572
428 Greenhill Road Invoice No: 4749
Mocksville, NC 27028 Billing Date: 4/11/2005
Sry Date Service Code ID/ATC# Description: Sry Cost Quan. Extended Cost
4/11/2005 SEPTIC-REP-R 2504 A 428 Greenhill Drive-27028 $50.00 1 $50.00
Balance Due Now: $50.00.