130 Little Rober Rd ;:..��s ,,..�:�..��r .� ,,._��,.-.F �;..;-s, <.r.:-:t :..�t:- ,.y..:� � , ,; . .� . '.�a� � �-z.. - , _-_ ,
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.,Permitt�e's�� " • .� " � AVIE COUNTY HEALTH DEPARTMENT
Name:� e`�y� x''r"�, T�/�'�j � � r Environmental HealthSection PROPERTY INFORMATION
r .^-: t J ,,' P.O.'Box 848'
Directions to property:��'�'ts�r �: ,%�'' �� �'" Mocksville.NC 27028 Subdivision Name:
,,,�i',f . Phone#:336-751-8760
,�' r ,,fi,:�i,'r``�. Section: Lot:
. '" ' AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTF.M CONSTRUCTION -
AUTHORIZATION NO: ���� , A ; ' Road Name: Zi
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**NOT'E**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 lnspections
Office when applying for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ,
� , , � ` �,� �,�a , /� ; . ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
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r. � .-., �-•� �_ '��� r ,�'�r-, t.: " IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUEb
RESIDENCIAL SPECIFICATION:BUILDING TYPE / � #BEllROOMS�#BATHS #OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE " #PEOPLE #PEOPLEJSHIFT #SEATS ' INDUSTRIAL WASTE:Yes or No
�
LOT SIZE TYPE WATER SUPPLY �d DESIGN WASTEWATER FLOW(GPD)���NEW SITE REPAIR SITE�f `
/ �� �(� ri f�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �tC� ROCK DEPTH LINEAR FI'.�v
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: - ` ` , , :
IMPROVEMENT PERMIT LAYOUT
. � � . . . . � . . � . . . � . . � � � � . . _ . � � . . �1��. ,.
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**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.
OPERATION PERMIT, � ,•: � ,
' SYSTEM INSTALLED BY: /�e �}�/
. �
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AUTHORIZATION NO����OPERATION PERMIT BY: DATE. d
**THE ISSUANCE OF THIS OPE�TION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTTH ARTIC�E's l l OF G.S.CHAP'fER 130A,SECI'ION.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.
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� �" ; � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ��0�
� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
o NAME �/1�_c S �-L �/�e. �� PHONE NUMBER� � 9�'- �-dr�',P'
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,1 ADDRESS f� v �-E-�-I-e- �o�e_2 l�ol • SUBDIVISION NAME�C. / 7�--� �s i-
~C I�-t�- v Q h�P . N L-- LOT#
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�d DIRECTIONS TO SITE � .1-- � n p�G •�...,_.� � � Ii /h /e
a ('[�o S S c� J e Q y L�U- �S�F-/LvL \��J �a ��� V LJ �-�,�1�- ��er - �-c� e.t�.
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� DATE SYSTEM INSTALLED����^'S �NAME SYSTEM INSTALLED UNDER S�4Jz � C7Qrr�.,� ��
� TYPE FACILITY � NUMBER BEDROOMS � NUMBER PEOPLE SERVED 7
� TYPE WATER SUPPLY C`��`r`��` SPECIFY PROBLEM OCCURF�ING !P�-�-,�-�r� �- ��/����
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DATE REQUESTED Z` ( �-y�o-f INFORMATION TAKEN BY �-� �
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This ie to certify that the in}ormation provided is correct to the best of my knowledge,and that I understand I am responaible}or all charpes incurred irom this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
qev.1/93
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