2193 Milling Rd (2)PermitteeDAVIE COUNTY HEALTH DEPARTMENT f
10 Name: H -3r' -r%' Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 z:
Directions'to property: :`� �' / mt' Mocksville, NC 27028 Subdivision Name:
�^ ,+^ hone #: 336-751-8760
��jl—ct �i n% /L i?' Section: Lot:
AdYWASTEWATER
THORIZATION FOR
Tax Office PIN:# - -
1" �p �p SYSTEM CONSTRUCTION
AUTHORIZATION N0:" "�*" .# A Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County EnvironmrrFhtal Health Section prior
to issuance'of any Building Permits. This Form/Authorization Number should be presented to the Davie CoLAy Building Inspections'
Office when applying for Building Permits.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage. Treatment an isposal Systems)
? ~" ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,��,a(��'d IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL AEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE r / # BEDROOMS V #BATHS -2# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE/ # PEOPLE # PEOPLE/SHIFT / # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY C (� DESIGN WASTEWATER FLOW (GPD) �CPONEW SITE REPAIR SITE
it ��'
SYSTEM SPECIFICATIONS H TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH � LINEAR FT. L1 ,
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.
DMD 07/02 (Revised)-'� 3,0z), .
NAME �0
ADDRESS_
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER 7 1 5�--1 7 S 7
r a , I-- f a I '1 ,
NAME
LOT #
DIRECTIONS TO SITE �r�- ra-�� S �i- J-F� �"t"` `Oa-'{ 1170 �ds - �✓�
�- �., rwt ►r.�.-�,,-�-b o �s �'" �"L- �- �'l✓ c� �S �+N' �-� o� rn-o.6 �C �. i1. a� ¢S' -
DATE SYSTEM INSTALLENAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED z
TYPE WATER SUPPLY!L SPECIFY PROBLEM OCCURRING
DATE REQUESTED l t- 25""O3 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
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
T-0
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of 6.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME /.�i7; r,�r l ./ �. PROPERTY ADDRESS �1�1I ! h q �h �R rI DATE .-5 F15 - ewe,
LOCATION
SUBDIVISION NAME LOT NUMBER
SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS , # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE 'iJ'f TYPE WATER SUPPLY i o� DESIGN WASTEWATER FLOW (GPD) �/. (J NEW SITE f�f REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE Z�L2Q GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM,
IMPROVEMENT PERMIT BY /Z //
**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 (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
—a
O
FQ-."T
HORIZATION NO. Q fo OPERATION PERMIT BY DATE
ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIWD ABOVE HAS BE WlNSTALLED IN COMPLIPI CE WITH
CLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A !
WTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. i