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Permittee1- DAVIE COUNTY HEALTH DEPARTMENT
Nantas z�' Environmental Health Section PROPERTY INFORMATION
�J P.O. Box 848
Directions to property:"' 1 ,i'/ / Mocksville, NC 27028. Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
/ AUTHORIZATION FOR
'WASTEWATER Tax Office PIN:#
�, SYSTEM CONSTRUCTION -
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.I 1 of G.S.`Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r t/ IS VALID FOR A PERIOD OF FIVE YEARS.
!NVIRONMENTA "HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: ' FACILITY TYPE # PEOPLE # PEOPLE/SHIF I` # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM TANK SIZE/
GAL. PUMP,TANK GAL. TRENCH WIDTHS �a ROCK DEPTH LINEAR FT. yL�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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.
DCHD 07J02 (Revised)�/ `- � -2— 17
d
r
• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME 7fiM 'e S All lei 6S� ti PHONE NUMBER
ADDRESS 6L t U (j )0y\ . SUBD V ION NAME
n L
LOT #
DIRECTIONS TO SITE�G';`� ��' G� -Jl�t .�tG`-�`Z> •�
Y
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITYNUMBER BEDROOMS NUMBER PEOPLE PERVED
` ,Q r
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING4-Gt _ � f_[h of
DATE REQUESTED ✓ 6 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