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156 Oak Grove Church Rd**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 FonydAuthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I 1 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 DA E— 1S1�S[JED RESIDENTIAL SPECIFICATION: BUILDING TYPE };- # BEDROOMS # BATHS # OCCUPANTS t'> GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No J /,vr.%'r LOT SIZE �' ! �PE WATER SUPPLY �'DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/ G�L7 GAL. PUMP TANK GAL. TRENCH WIDTH �(^ ROCK DEPTH ' , LINEAR FT. OTHER l lJ+ 1'1✓. L l r REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "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 AUTHORIZATION NO. D!A OPER, "THE ISSUANCE OF THIS OPERATION PEE WITH ARTICLE I 1 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. SYSTEM INSTALLED BY: bk4A DCHD 02/02 (Revised) 9 / s o �,,✓� � fo 93 PJlrmittee s ,. DAVIE COUNTY HEALTH DEPARTMENT . Name: Environmental Health Section PROPERTY INFORMATION s'- ( 1 P.O. Box 848 1 ' Directions toro ert : P P Y '' Mocksville, NC 27028 Subdivision Name: " Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION AUTHORIZATION NO: �� � 6 ' � A r Road Name: ' (� �^ I r frl � 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 FonydAuthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I 1 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 DA E— 1S1�S[JED RESIDENTIAL SPECIFICATION: BUILDING TYPE };- # BEDROOMS # BATHS # OCCUPANTS t'> GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No J /,vr.%'r LOT SIZE �' ! �PE WATER SUPPLY �'DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/ G�L7 GAL. PUMP TANK GAL. TRENCH WIDTH �(^ ROCK DEPTH ' , LINEAR FT. OTHER l lJ+ 1'1✓. L l r REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "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 AUTHORIZATION NO. D!A OPER, "THE ISSUANCE OF THIS OPERATION PEE WITH ARTICLE I 1 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. SYSTEM INSTALLED BY: bk4A DCHD 02/02 (Revised) 9 / s o �,,✓� � fo 93 "P6rrnitCe� DAVIE COUNTY HEALTH DEPARTMENT �. NaineM: ; "\ 1 ` Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: - "+ ` Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: ,kUTHORIZATION NO: AUTHORIZATION FOR WASTEWATER Lot: SYSTEM CONSTRUCTION Tax Office PIN:# - - "�� g} 2p 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) a j ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '-` ! IS VALID FOR A PERIOD OF FIVE YEARS. s ; a ENVIRONMENTAL HEALTH SPECIALIST DAR ISSOED RESIDENTIAL SPECIFICATION: BUILDING TYPE l'-�L # BEDROOMS # BATHS ( # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE ' ' `f 1 TYPE WATER SUPPLY L DESIGN WASTEWATER FLOW (GPD) =� NEW SITE REPAIR SITE �- SYSTEM SPECIFICATIONS: TANK SIZE l GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �- LINEAR Fr. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: Pvr° t' 1 ' a" `T 'r4 I''�r I ` (1'44 IMPROVEMENT PERMIT LAYOUT **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 . AUTHORIZATION NO. " S J - OPER. SYSTEM INSTALLED BY: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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) /.13 A -t ; g DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME (mow PHONE NUMBER 'ISI 1�5 to �4� C �= Cts � ADDRESS / SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED 1 y5� 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. 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