809 Hwy 801SPerm. s
DAVIE COUNTY HEALTH DEPARTMENT--�
game: rl ��f�i *L �� �i Environmental Health Section PRO ERTY INFORMATION
P.O. Box $4$
Directions to property: L\ 6. Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
ALLLt y `� Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION NO: 9 1 1A Road IVam�� O VY 1,D i � Zip: �'7
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County EnvironmentalHealth Section prior
to issuance of any Building Permits. This Fom-i/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits. -
(In compliance with e 1 I ` W
. of '§. Chapter 130A,astewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
d _ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENV14 EfitTAIrH H SPEdIALIST DATE ISS ED
RESIDENTIAL SPECIFICATION: BUILDING TYPE _Qt # BEDROOMS # BATHS # OCCUPANTS
Z 7— GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE'r'iyQb� TYPE WATER SUPPLY`,'"" ' ' I DESIGN WASTEWATER FLOW (GPD) ��OC NEW SITE REPAIR SITE r
SYSTEM SPECIFICATIONS: TANK SIZE 1 OTGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER n iJ1sT��/�•�V.►��'' t �1�7�QLL 1�1�v�� . 1 •C. 6�1 t�
/�
REQUIRED SITE MODIFICATIONS/CONDITIONS: �
__ OSTALL dfi! COJQ i�Y�'t ' , '� f' •; tL.1r InJ >+-t�
.r0-jV
"*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.
AUTHORIZATION NOC;&OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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 02102 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT A ��
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760 Rory 9 1002
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instru ons.
1. Name to be Billed i�l,), L L J Q In`!_�/►% �, a Contact Person
Mailing Address _P (� b.�.� Q `i Home Phone
City/state/ZIP A1V4 fV G C �7a o A Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC YBoth
4. System to service: Y.House ❑ Mobile Home ❑ Business ❑ Industry ❑ Othe
5. If Residence: # People 22 # Bedrooms # Bathrooms _
Dishwasher XGarbage Disposal AWashing Machine 1 Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ANO
If yes, what type?
'**IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBM17YED by the client with THIS APPLICATION.
Property Dimensions: �"� %� 7 WRITE DIRECTIONS (from Mocksvilie) to PROPERTY:
Tax Office PIN: # 19 G/2 d 55 ,
`.{'O ri1 O j� li
Property Address: Road Name -X11C ,yk),J)/ &eJ/ S V %� t 1, E di ' 6A) VO 1 s�
city/zip �}�, v 1�lri%G E �7a a b
If in a Subdivision provide information, as follows: y
Name:
• f _ )i�g1�z
Section: Block: Lot: Date Property Flagged: "e'X/ S i „
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE _,0 �ZiG 1loom, SIGNATURE ],�9
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
d Client Notification Date:
Ste` Account No.
52$`
Revised DCHD (07/99) � Invoice No.
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