1474 Hwy 64W Pennittee's r '—: t DAVIE COUNTY HEALTH DEPARTMENT
Y Name: / �' t�'_ � �' / {��7 Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: 1 l-4 = � `�1 (� Mocksville,NC 27028 Subdivision Name:
Ii 11 (( Phone#:336-751-9760
` l � �! �k,Cj1 �f t� .� C iC�'( Section: - Lot:
AUTHORIZATION FOR y {,
WASTEWATER
SYSTEM CONSTRUCTION, Tax Office PIN:#
AUTHORIZATION NO: 003033 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 compliance with Article I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
) om SIP/?v r IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPIALIST DA E ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS J #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(&At\Y( DESIGN WASTEWATER FLOW(GPD) 51 .�ONEW SITE REPAIR SITE— 77
SYSTEM SPECIFICATIONS: TANK SIZEa(S��AL. PUMP TANK GAL. TRENCH WIDTH— _*,j_ ROCK DEPTH / LINEAR FT.
OTHER ��4 1(�
REQUIRED SITE MODIFICATIONS/CONDITIONS:-x-\J` \ (1 `W - O n. / ,
IMPROQ�EMENT PERMIT LAYOUT �(
x�DIv
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.
OPERA'TJQN PERMITtr C�CaG��6 �
W vw J ,!V�:tl„f�(S�l►` SYSTEM INSTALLED BY:
A. ���I . � -
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AUTHORIZATION NO&Q OPERATION PERMIT BY: DATE:V 20/
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES IBED 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.
DCHn 02/02(Revised) T SS7 T . vik,-/` 7J S.27
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i - -y.♦ -,'-s-.. ra'�t'...+ `�k'-r�lI".: ';�4.1r �'r.Ypt.�:r J:;•.v '3�.
] ttee s DAVIE COUNTY HEALTH DEPARTMENT
`y Kame: A ( t � 'i`' + Env ronmental Health Section PROPERTY INFORMA ION
x ✓� s` t ; C P.O.Box 848 {
Direction§to pro 5ty:. `� t', s Mocksville,NC 27028 _ Subdivision Name:
t
Phone� #:3 36-751-8760
Section: Lot:
AUTHORIZATION FOR t�^
WASTEWATER.' Tax Office PIN:# J� (� 41d�
ry SYSTEM CONSTRUCTION
AUTHORIZATION NO: 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 compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems)
l t ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
c: k 1�j {its. � � J r ',J ( 't IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SP�qIALIST DA E ISSUED
j
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 � �t' DESIGN WASTEWATER FLOW(GPD)�LONEW SITE REPAIR SITE t r"
,Zoo
SYSTEM SPECIFICATIONS: TANK SIZE` (�' L. PUMP TANK /A GAL. TRENCH WIDTH {Q ROCK DEPTH / LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: C..j� v -f4 tom( ✓a, &-kie
IMPRO�ENT PERMIT LAYOUT 75
0.01
i
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.
OPE IQN PERMIT j f//,,�/ /`� j�/ v
N \ voo j G{�(j/��I� SYSTEM INSTALLED BY: c-. C� C.y (�L`l U
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AUTHORIZATION NO. OPERATION PERMIT BY: DATE: �IP >o/
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES RIBED'ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
ocHD 02102(rt vised) ,l� �-i Ss75� �.t�3+•` 7.Sy. 7
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME No fLi'-psL PHONE NUMBER
ADDRESS SUBDIVISION NAME
//-? e LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER UJ 6f"►e#
TYPE FACILITY L NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY (,lid SPECIFY PROBLEM OCCURRING �(ALW
DATE REQUESTED 2010 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