1028 Markland RdDAVIE.COUNTY HEALTH DEPARTMENT
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Name: -`fir/��r� /.�, Environmental Health Section PROPERTY INFORMATION
a P.O: Box 848
Directions to property: ?'+ f '/'til 17 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
yY fi3liti •�'i' .�"' J ' .i ~ ` IS VALID FOR A PERIOD OF FIVE YEARS.
E VIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS_ #BATHS # OCCUPANTS _,/_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE,/ # PEOPLE # PEOPLEISHIFT �# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY ` U DESIGN WASTEWATER FLOW (GPD) &wl6/) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE , GAL. , PUMP TANK ' GAL. ,TRENCH WIDTHzi�t ROCK DEPTH ? 'LINEAR F ',a
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 02102 (Revised)
' 1
NAME
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
UBDIVISION NAME
17
ITE ),eK- /--
DIRECTIONS TO S f
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY /7 -NU MBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING M
DATE REQUESTED 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 t