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AtiT-AUTNO: I j.717t DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
_Permittee' P.O.Box 848
Name: `: Mocksville,NC 27028 Subdivision Name:
+�.. Phone# 336-751-8760
Directions to property: �iw Section: Lot:
AU OR
WASTEWATER,
SYSTEM CONSTRUCTION Tax Office PIN:# - -
Road Name: Zip`. 27oZ�
**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 F6mVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln co pliance with Article l l of G.S.Chapter 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t "/✓` l/ IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTALHEALTH SPECIALIST DATE ISSUED
I 7 7XDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pi
-Name Subdivision Name:
Directions to property: 2Mt%� •. Section: Lot:
'► 1q mr t E%1PROVEMENT
a
PERMIT Tax Office PIN:#
.. Road Name: 96/s Zip: Z 7oz;:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER "
NVIRONMENTAL"HEALTH SP DATE ISSUED SYSTEM CONTRACTOR MUST,SEE THIS PERMIT BEFORE..
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS
_L#OCCUPANTS GARBAGE DISPOSAL.Yes or No
COMMERCIAL SPECIFICATION: FACILITY,TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
.LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) �NEW SITE REPAIR SITE'-
00 i 'LINEAR`/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHy ROCK DEPTH
/C� FT.�v
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*APPROVI_D'EFFtUENT"FI ER* *RISER(S) IF G" BELOW FINISHED GRADE*
1 4
**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(704)6348760.
XXXXXXXXX
0
OPERATION PERMIT
AUTHORIZATION NO, OPERATION PERMIT BY: DATE:
**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.
DCHD 05/96(Revised)
J }
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
r
NAME f h �. LC �. Ji1�� >°.2 PHONE NUMBER
ADDRESS- --7 / O 14,-, \r b I S SUBDIVISION NAME
O C,K S (/ l rj C LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
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 responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93