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292 Junction RdPeknittee's�' ' ' "' J DAVIE COUNTY HEALTH DEPARTMENT Name � �J`! 1 ©% Environmental Health Section PROPERTY INFORM NI _f P.O. Box 848 Directions to property:-- BIZ~• 1 f' /r')!i ? I� y Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: f ) ' AUTHORIZATION FOR l" / WASTEWATER SYSTEM CONSTRUCTION Tax Office PPI�IN:# - - AUTHORIZATION NO: 002669 A I�d Name. µluC�� lw! ` zip.2,7026 **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. (Incompliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) �, • ! % . ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION i� %� /✓ "e: -z%`! '' !r� %/z' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE_ # BEDROOMS,.p # BATHS # 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) s� d NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH��(– ROCK DEPTH/ LINEAR FT*:J�.. REQUIRED SITE MODIFICATIONS/CONDITIONS: lc 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED BY: 10 71.2 i�K4 AUTHORIZATION NO. �j�� OPERATION PERMIT BY: DATE: E9� `If��--'�— "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 02102 (Revised) �,, _-.. t : ., ...,,...,.�.......,.�,,. ?.;� .fes xr,. r -'.y «. .•...�..w.o �.t>. i .. r ... - ,-: Y i ee kPelfimilf ..' DAVIE COUNTY HEALTH DEPARTMENT (p 1 Environmental Health Section PROPERTY INFORMA 4". P.O. Box 848 Dircctig4s to ro erf`i �� ,✓k„r "r " •, / ` ,`" P Y Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 V Section: Lot:. 1, AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - Z g.Z � rue �; v,y �� 2702 AUTHORIZATION NO: ®Qt A Road, Name: Zip: **NATE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Da4County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presentmtto.the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I I of G.S Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) Y ; t ***NOTICE*** THIS AUTHORIZ'A'TION FOR WASTEWATER CONSTRUCTION IS VAIJD FOR;A—PERIOD OF FIVE YEARS.... ENVIRONMENTAL HEALTH SPECIALIST ATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE_ # BEDROOMS # BATHS# OCCUPANTS GARBAGE DISPOSAL: s or No 4— COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS 'INDUSTRIAL WASTE: Yes or No r LOT SIZE TYPE WATER SUPPLY' DESIGN WASTEWATER FLOW (GPD) `� �' NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH'15 �'—'ROCK DEPTH t ✓i LINEAR FT. ) OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: l IMPROVEMENT PERMIT LAYOUT , u. r ad,r r a 4- 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. w OPERATION PERMIT SYSTEM INSTALLED BY: 1 f 1 T r .. Y OPERATION PERMIT BY: DATE: / / AUTHORIZATION NO. �� **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 02102 (Revised) res how Z23 /q 95 IV-h1a',5q, DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION I„t�C SVII ie APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) 21 NAME Rididial ShaiS PHONE NUMBER ADDRESS 2-qA&kU.7le-SUBDIVISION NAME 11 tf //1s �2en��4S LOT # DIRECTIONS TO SITE _l �C � C/1/L_ 'tel 0� DATE SYSTEM IN AILED NAME SYSTEM INSTALLED UNDER No sure, TYPE FACILITYeNUMBER BEDROOMS NUMBER PEOPLE SERVED Z TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING )qddd <<R4;W u C - r DATE REQUESTED `'l D tel/ 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 r} w e , i i ( � , a A e � r ',rTw"s6 f + r 4y : n AM \e ..+ A� t 1 fliL .. NOT.'p^ g i