385 Junction Rd Permittee DAVIE COUNTY HEALTH DEPARTMENT XRMATION
Name `Vt.�j ��l:� ��{[S� Environmental Health Section PRO Y I
P.O. Box 848 "alk/L Directions to property: `' "`' °` ��"t Mocksville,NC 27028 Subdivision Name:
Phone#: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002702 A 4Zad Name:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen-nits.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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f' ,�`''f�� ' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE eLV #BEDROOMS #BATHS sem_#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY jG DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `' ROCK DEPTH LINEAR FT.
As stetetl in 15A NCAC 18A.1969(5)
OTHER cinnepted SyStenls may also be Used
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
d
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.
OPERATIOIQ-FERMIT � ,Vt ��� ��n PIN
INSTALLED BY:J /'�
s� `Trk=mG
, 3b
AUTHORIZATION NO. D 2,71) OPERATION PERMIT BY: v DATE: 1C _Z7_e&
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE AT 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 FUNNCTION SATISFACTORILY FOR AI',Y GIVEN PERIOD OF TIME. Z-�
nctln 02/02(Revised)> �V�� ■NP�*1IV%
Permittees DAVIE COUNT. HEALTH DEPARTMENT t�
Name:� �an&. lkwwc _� Enver nmental Health Section PROP Y INFORMATION
"y .0. Box 848
"fidygle���r�s
Dlrectlons to property: ~' Modsville,•NC 27028 Subdivision Name:
, Phone#:336 41,8,760
�•`. Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION /- -
AUTHORIZATION NO: 00 Q �, Koad NaYnU n /6/ ? /f?Gl' Zip; 2-7 0 ZR'
**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 11 of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.,.IS'VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED" r"
RESIDENTIAL SPECIFICATION:BUILDING TYPE_ f #BEDROOMS, #BATHS #OCCUPANTS_ GARBAGE DISPOSAL:Yes or No
N
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS ,"INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ��G DESIGN WASTEWATER FLOW(GPD) ' NEW SITE REPAIR SITE
`.SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 'Y
r�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
011'S e.
6,.'.3X1
� V
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.
OPERATIONT RMIT I,,
11)i YSTEM INSTALLED BY: /'e-A ro d—
�/�
S��`�
at\ *1 /Up r QtI mG r C
1
AUTHORIZATION NO. n o 7 D Z OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE., AT 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 TH( o� I
THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEr-;,ff RIOD OF TIME. -
DCHD 02/02(Revised) i {/,��
v'1 #-4115--1 5729'
c �' /e lU a"✓
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �7
r CQGUIIl�1Z) APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)(9 /, � ��`��
NAME (Sird use, PHONE NUMBER /s��7 DJ"�7
ADDRESS ,5�� c JGI/VC�I d� �'l t�� 11r�`2 NC SUBDIVISION NAME
-"4jj.h
i"
//?�
/�()'l1 LOT #
DIRECTIONS TO SITE 00 �s�Iu� Zt/Jfl/�jG/Sr1�� • �d 'C�rUAM711U4UI-�
A14 14 hl 4, Oce a o 14 E -�'eh- i�
dA'T'#I§STEM INSTALLED91A'/' /q/41 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY rfi ENUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
rein �a!nf oNCMporT
TYPE WATER UPPLY SPECIFY PROBLEM OCCURRINGs�� /� Sedt.�?�E'
&j4j IaitI0136110(p 414�14 MR aatlik), A
DATE REQUESTED &b-OZ/ INFORMATION TAKEN BY i
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
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