1828 Hwy 801S.Permitteg's )' DAVIE COUNTY HEALTH DEPARTMENT
Name: .i��'' ,4 �-rnm-y%'� Environmental Health Section PROPERTY INFORMATION
`- �/,+ t/ P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
,� � Phone #: 336-751-8760
letg- °,�., .��51' 1'7, i",^ _ __ Section: Lot:
AUTHORIZATION FOR
/ WASTEWATER
/!� " j'�.: Tax Office PIN:#
SYSTEM CONSTRUCTION
N AUTHORIZATION NO: 8. 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.
1
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** :THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
fes, IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUE16
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS'- # BATHS —..2— # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY 1",6?. DESIGN WASTEWATER FLOW (GPD)1? NEW SITE REPAIR SITE '~
SYSTEM SPECIFICATIONS: TANK SIZE 1aaGAL. PUMP TANK GAL. TRENCH WIDTH /ROCK DEPTH LINEAR FF. -LQ O
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
AUTHORIZATION NO. OPERATION PERMIT BY: ✓✓✓ DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL'INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street U
Mocksville, NC 27028 AIG
Phone: (336)751-8760 4 ?004
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ON-SITE WASTEWATER CERTIFICATION FOR DWE �DR0MI fj,
(Check One) REPLACEMENT ❑ REMODELING [Y RECO NEC
Name: z mm� 0 CA1 ()'^f'P / Phone Number:.3-U /� � � 04- (Home)
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Mailing Address: !� • d • R`' e -,7/ q%4 -7"Z1 - -74R
(Work)
My0Nc /v •C . 2"7 � 0,6
Detailed Directions To Site: 8 2 $ y % Y 7-- 7777"
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Property Address: t, ' y
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: r0#1 / < ra Y Type Of Dwelling: Jfy O ws A—
Date System Installed(Month/Day/Year): 7Z --X Number Of Bedrooms: Number Of People:
Is The Dwelling Currently Vacant? Yes ❑ No 8--'V Yes, For How Long?.
Any Known Problems? Yes ❑ No fd/if Yes,
)i --cul t, rvk Ae'tr) -4 -
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling:A- 'L Number Of Bedrooms, Number Of People:
Requested By:1( ann�
Date Requested: tT'"ZL// '- V
(i�� )
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments
Environmental Health Specialist Date
'"The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) t the on-site wastewater system will function properly for any given period
/of time.
O - 7 a 7
Payment: Cash ❑ eck oney Order ❑ # C2 ��� Amount• $ j o 0 on Date: Ll
Paid By: Received By:
Account #: ` .' Invoice #: 7 i