829 Hwy 64 W � F pot,,&, a
Permittee's , DAVIE COUNTY HEALTH DEPARTMENT
Name: /-/,111 e", f Environmental Health Section PROPERTY INFORMATION
-r 11�p ' �'d1�✓yr �j�s-"�`' ' �'. f;/ P.O.Box 848
Directions to property: Mocksville,NC 27028 Subdivision Name:
Phone#:336-751-8760
6;V Section: Lot:
tai ,l c, AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
d, SYSTEM CONSTRUCTION
AUTHORIZATION NO: 2235 A Road Name: L q Ltd Zip: Z70ZP'
**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 1 of G.S.Chapter 130A,Wastewater Systems,.Section.1900 Sewage Treatment and Disposal Systems)
,r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 1
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL H ALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE_ #BEDROOM4 #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or N''o"�
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPT LINEAR FT.,�6
OTHER t y ix
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
t�
10
I
k .
**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 (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: �� ('l-
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AUTHORIZATION NO. � M OPERATION PERMIT BY ATE: L'O
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S M D SCRIBED ABOVE H B N INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT A ISPOSAL SYSTEMS", UT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
I M
NAME ,
�� �-^� s ° rr—� - PHONE NUMBER
ADDRESS 3 d ° �'�- �sy e SUBDIVISION NAME
(moo C. ,� '� l L
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
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N
DATE REQUESTED INFORMATION TAKEN BY t
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