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AUTHORIZATION NO: 0 6 4 8 DAVIE COUNTY HEALTH DEPARTMENT
,. Environmental Health Section PROPERTY INFORMATION
Perniittee's P.O.Box 848
Name: Mocksville,NC 27028 Subdivision Name:
�3phone#:704-634-8760
Directions to property:
tl0 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION 13�-I r1
Road ame: Zip: /0.
**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.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
6.;
7 ,
7" DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
k Irerrrutiee's. � �f ame: �
,
� Subdivision Name:
N ;. !r .. ..-r
Directions to property: Section: Lot
IMPROVEMENT
PERMIT Tax Office PIN:#
Road ame:i W. Zip• -A
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
r . ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE ElaTMED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE_ / #BEDROOMS #BATHS #OCCUPANTS c�: _GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION:'FACILITY TYPE #PEOPLE #PEOPLE/SHIFr #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WAUR SUPPLY DESIGN WASTEWATER FLOW(GPD).__19 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE-. GAL. PUMP TANK GAL. TRENCH WIDTH„ ROCK DEPTHLINEAR FTc2Q
OT4ER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT,
r
"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(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
U e �ecop d,
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Pd
C� sa
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AUTHORIZATION NO. $ 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.
DCHD 05/96(Revised)
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. .. y, ,�"r�•,��+`"+�r�M`"q�"'ef.�Y".T •c`w,V+;rr•'y�'li''',��'�`Y!'�. �i�,Y� .�'...,,%."Fi�^�""�' a: -,.w.>✓ i*n'LY�'vf'i�C�,;i j `�yY�!'t51Y".
* * i DAME COUNTY HEALTH DEPARTMENT
IMPROVEMENT:AND OPERATION PERMITS PROPERTY INFORMATION
i�ernuttee's ,.
Name:.- , Subdivision Name:
Directions'to property' '��' c `d s. Section:' Lot:;
_,. IMPROVEMENT
i PERMITTax.Offce PIN:#
Roadt 44 W. Zip �.�
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.Ari,
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
consti uction/mstallation of a system or the issuance of a building pem�it
(In compliance with Article-11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERD*HT IS SUBJECT TO REVOCATION IF SITE.
' PLANS OR THE D T MED USE CHANGE.YOUR WASTEWATER.
' ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED - SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE.SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE_ #BEDROOMS •#BATHS_ #OCCUPANTS GARBAGE DISPOSAL:Yes or No
10
COMMERCIAL SPECIFICATION:4kkCR=- TYPE #PEOPLE �c #PEOK&SHIFT #SEATS INDUSTRIAL WASTE:'Yes or No
LOT SIZE TYPE WAR SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE L/
SYSTEM'SPECIFICATIONS: TANK SIZE, GAL ..PUMP TANK GAL. TRENCH WIDTIJ oel ROCK DEPTH/ LINEAR FT
it REQUIRED'SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT•PERMIT LAYO
• - ��/y /,gip � _�.'''----"'"" - .• '
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-#:30 A.M.OR 1:00'-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704).634-8760.
t a
OPERATION PERMIT /
�•
' SYSTEM INSTALLED BY-. '
AUTHORIZATION NO.'
.�6 I OPERATION PERMIT BY.
"*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]BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised) . .
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME XJ/iitr� )�'�/�Jr'.` 7� PHONE NUMBER
ADDRESS llll `-,64ro iOZ>tl ��kO SUBDIVISION NAME
loel i-//.l/ LOT#
DIRECTIONS TO SITE "air o'g 7-- 111/ y
re,4 )\Dt y/
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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