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HomeMy WebLinkAbout3746 Hwy 801S PermiiiP s,' DAVIE COUNTY HEALTH DEPARTMENT 2- 0 v/ Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to proerty: �r:;/ Mocksville,NC 27028 Subdivision Name: .- Phone#:336-751-8760 Section: Lot a AUTHORIZATION.FOR WASTEWATER SYSTF, 'CQ RUCTION Tax Office PIN:# - - AUTHORIZATION NO: . :'A ��'r, Road ame: Zip: **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 I 1 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 ISS ED 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 y�% - DESIGN WASTEWATER FLAW(GPD) LW NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ' 4' LINEAR OTHER REQUIRED SITE.MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 4 v�� r **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALT DEP TMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-'1:30 P.M.ON THE DAY O INST LL�N.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: fJ O+G 8 fi r AUTHORIZATION NO.X " T 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 BE TAKEN AS A' GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. , I)CriD 07102(Reused) , o :60 r � , '4t ©o DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �" L /►��. �e-7 APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)rvY� NAME PHONE NUMBER ADDRESS (fQ S SUBDIVISION NAME LOT # DIRECTIONZM SITE (O �.v L �� a ��S R-�J� �c -e-, DATE SYSTEM INSTALLED Z NAME SYSTEM INSTALLED UNDER ► C4 -e' /-a h l e, -e -- TYPE FACILITY NUMBER BEDROOMS 13 NUMBER PEOPLE SERVED TYPE WATER SUPPLY �/�I.,L, SPECIFY PROBLEM OCCURRING & �IXC 'tet Y o a/"- — -4-6-01<f . 0 o 'J A." DATE REQUESTED a Y INFORMATION TAKEN BY This is to certifythat the information provided is correct to the best of m knowledge, and that I understand I am responsible for all charges incurred from this application. P Y 9. Po fl SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 Davie -,County Health Department 336 Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 .1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: (0 a Phone Number 33(� - (Home) Mailing Address:.?7! (46 /2) C f U14 i So«� 3 (-Wank) t V C 7 GCS 4P Email Address: i .. Detailed Directions To Site: Property Address: Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: P r Type Of Facility: Date System Installed (Month/Date/Year):.2 - ,2 Number Of Bedrooms:_Number Of People: Is The Facility Currently Vacant? YesNgo If Yes, For How Long? Any Known Problems? YesNo If Yes, Explain: PleaseXill In The Following Information About The NEW Facility: Type Of Facility: 764 s , Number Of Bedrooms:IVI� Number of People Pool Size: Garage Size: X7/1; Other: Requested By: z2_ ., Date Requested: /P (Signature) For Environmental Health Office Use Only Approved ) Disapproved Environmental Health Speciali *The signing of this form by the Environmental Health Date: is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: pasji.% Check Money Order # Amount:$ /Od - VD - Date: Paid By: K . �; yA f u-.- Received By: q�_t,. Account #: „ !{! _Invoice #: / /