587 Liberty Church Rd-40
Permittee's DAVIE COUNTY HEALTH DEPARTMENT F�
Natnz_: t// Environmental Health Section PROPERTY INFORMATION
+�►,J�� t P.O. Box 848
Directions to property:'/ %�' �s '."%j �r�� ` �s `' Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION 5 9r J
AUTHORIZATION NO: 002649 A Road Name: t .. " l k, Zip: 07S
**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 l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
i , ,
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS - GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
I
LOT SIZE TYPE WATER SUPPLY / �j '� DESIGN WASTEWATER FLOW (GPD) �� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH /_1y LINEAR FTv^�Jd
OTHER
As 5tdted in 15A NCAC 18A.1969(5)
accepted Systems may also be usedd
REQUIRED SITE MODIFICATIONS/CONDITIONS:`
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.
OPERATION PERM r Z G
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SYSTEM INSTALLED BY: S tnw.o�u►vw�
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AUTHORIZATION NO.
ZL� 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 NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
neiinovoz (Revised) fi 1933 J u606-1 y .; y70
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Pernii DAVIE COUNTY HEALTH DEPARTMENT
Narrle i J Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
1; w i
DtrectinnS to property: C f ' Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
-- AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002649 A Iroad Name
**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• Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION'
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE _ L # BEDROOMS 47 # BATHS --44# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY A DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH / LINEAR FT' ' i
OTHER
_. stated In 15A NCAC 18A.1969(5)
REQUIRED SITE MODIFICATIONS/CONDITIONS: .accepted Svstemq may also be usedd
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.
OPERATION PERMI,� 2
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SYSTEM INSTALLED BY: Pn w� o� �u h •ti
t AT � I
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6
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: J
**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) p � , � •—�t l ! 63 �N UV iC V y7v
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION6
PP CATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME -,16; PHONE NUM R -72
ADDRESS Z� P/ A"W4' bP r' I)y SUBDIVISIO NAM
DATE SYSTEM INSTALLENAME SYSTEM INSTALLED UNDER i
TYPE FACILITY_NUMBER I /� NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY /_ K SPECIFY PROBLEM OCCURRING �Gli`� 1
DATE REQUESTED�/f� 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