7093 Hwy 801SDA C TY HEALTH DEPARTMENT ^?
Pemnttee.
9 'Names' �C:I�P En nmental Health Section, PROPERTY INFORMATION
t / P.O. Box'848
., birecdons to property: C.+ 1'L �` / ocksville, NC 27028 Subdivision Name:
ne #:.336 751=8760
° Section: Lot:
'AUTHORIZATION FOR s
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 2363 A F 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'�mpliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r " • : i# f'/' f, �,� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE » #•P,EOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No :
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) y �[/ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ,LC LINEAR
OTHER .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
x
8
J 4
v
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME D PHONE NUMBER a < �-
�--�� \ - 7��_� �-- S37s A-- -coda
ADDRESS z 3 01 S SU IVISION NAME
0C_�CA ✓ LOT*
DIRECTIONS TO SITE `� i S 6D
%2 3 ALL Clt' C..) t_4--(,
DATE SYSTEM INSTALLED r-5 NAME SYSTEM INSTALLED UNDER ? /
TYPE FACILITY NUMBER BEDROOMS _NUMBER PEOPLE SERVED 2
TYPE WATER SUPPLY a t, --,L SPECIFY PROBLEM OCCURRING it
DATE REQU
NFORMATION 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