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DAVIE COUNTY HEALTH DEPARTMENT-
Environmental
EPARTMENT Environmental Health Section PROPERTY INFORMATION
% P.O. Box 848
Directions to property: /r ` r cksville, NC 27028 Subdivision Name:
� Phone #: 33¢-751-8760
%r'�1G%�.=��'* �', r%✓' C f Section: Lot:
AUTHORIZATION, FOR
✓ f!i1 r`�e'r'L ./ r''ir'l'/`� r'r" WASTEWATER Tax Office PIN:#
r SYSTEM CONSTRUCTION
2289
AUTHORIZATION NO: 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.'
(In compliance with Article 11 of G.S. Chapter 130A;
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
PPLIC`AfTION FOR IMPROVEMENT PERMIT (REPAIR)
NAME 1"-'v' PHONE NUMBER
ADDRESS ��� -I ��'`� I �� l� SUBDIVISION NAME
LOT #
r
DIRECTIONS TO SITE.. _ ;7-A o 413 ��
DATE SYSTEM INSTALLED 1 J C� NAME SYSTEM INST LLED UNDER r-7TYPE FACILITY NUMBER BEDROOMS 2 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING A(oa, �Vl'�,
�fl t /� �1ni `rp GYM
up
DATE REQUESTED Dq 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. 1193