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7099 Hwy 801S (2)Nrinittee's ("'`, " '""" '�DAM��E COUNTY HEALTH DEPARTMENT dame: t`�`4 �ti1r�`! I^ Environmental Health Section PROPERTY INFORMATION Y P.O. Box 848 ., Directions to property: o l 5 �� «� Iviocksville, NC 27028. Subdivision Name: Phone #: 336-751-8760 n►.i7 1.�t)�� , Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - c - t M AUTHORIZATION NO: 4 A Road Name. r- Zip:[ DZ **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: (I orfip ianc 1Ch.Artiz`1z'1 of G.S, Chpze 130A, Wastewater Systems, Section .1900.Sewage Treatment and Disposal Systems) /% . ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION Its G? ;'' IS VALID FORA. PERIOD OF FIVE YEARS. E VIRON E fiAL F,� PE ALIS AT ISS ED RESIDENTIAL SPECIFICATION: BUILDING TYPE:_NQ1%� # BEllROOMS #BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye or o COMMERCIAL SPECIFICATION: FACILITY TYPP�E�� # PEOPLE # PEOPLE/SHIFT �y # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZ A_&ft E WATER SUPPLY"'"' Z DESIGN WASTEWATER FLOW (GPD) j aw NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH_ LINEAR FT. OD OTHER ,,REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT )3 Ncrij DCHD 02102 (ReVlaw) I r: w- 41- —DA_ IE COUNTY HEALTH DEPARTMENT / -�'� Z` 0� V ame �`a i��'' ` i v >�>- t '� Envit onmentaLHealth Section PROPERTY INFORMATION _ur ctionsyt property:` ..) [� L.a r . t' +• 3 P.O. Box 848 Mocksvilie, NC 27028 Subdivision Name: Phone #• • 336-751-8760.. - _ Section: Lot: - AUTHORIZATION FOR - WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN :# - - � - AUTHORIZATION NO: A Road Name. .'4t, ;_ gip; .r is **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 Fon�n/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (I compliance �Ih.Arti7 e I],of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,�� ; t % �•s I / � - IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONYENTAL•HI:AITF�SPECIALIST�, �AT ISSUED Ny r i tl RESIDENTIAL SPECIFICATION: BUILDING TYPE t� '# BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye or IV j j COMMERCIAL SPECIFICATION: FACILITY, TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No . LOT SIZE TYPE WATER SUPPLY ''t DESIGN WASTEWATER FLOW (GPD) . % o "NEW SITE REPAIR SITE 1, i '� + SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK ' GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. _I OTHER LL. ,HJT ('� �C Ii'ItFQUIRED SITE MQDIFICATIONS/CONDITIONS: 1<� hIto 14J-' IMPROVEMENT PERMIT LAYOUT 'y t.OrMf t • 1.2t1C`- + **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. I N 15' (1� .4 AUTHORIZATION NO. OPERATION PERMIT B DATE: r „ **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA E ESCRIBE A OVE HAS BEEN INSTALLED I CO LIANCE WITH ARTICLE I 1 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. "DMD 02M (Revised) ; 4 � j N vDI S 2'j 0 ©nJ J, 11 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) ADDRESS `I�"C'1 11V3y �ol9 &,oe4<S DIRECTIONS TO SITE S 4cR45� PHONE NUMBER 2$4 260? SUBDIVISION NAME LOT # DATE SYSTEM INSTALLED /� NAME SYSTEM INSTALLED UNDER C-ApyLw c 'Pbt-Q� TYPE FACILITY W' NUMBER BEDROOMS 31 2 NUMBER PEOPLE SERVED 3 TYPE WATER SUPPLY (.l& SPECIFY PROBLEM OCCURRING 1+36 L,)P DATE REQUESTED 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 r�onsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93