488 Peoples Creek RdPenwitXe's. t DAVIE CQVNT(Y HEALTH DEPARTMENT
Name: �! � t •=� I"^� �" x'EnWronmental Health Section
j l: P.O. Box 848
PROPERTY INFORMATION
Directions to property: �_k—) I i{' c't-'f L,1, -Z '" Mocksville NC 27028 Subdivision Name:
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Phone #: 336-751-8760
Section: Lot:
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AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
Tax Office PIN:#
Road Name. t'' U t ,r•t i. Z.
AUTHORIZATION NO:
**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 FomVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliancepith Article I I of GS. Ghapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
c� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
0 -'3IS VALID FOR A PERIOD OF FIVE YEARS.
SPECIALIST ? DATE
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS�-�"""j # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
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COMMERCIAL SPECIFICATION: FACILITY TYPE )EOPLE `f+� "' # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE 1 �",TYPE WATER SUPPLY'DESIGN WASTEWATER FLOW (GPD) / `"� NEW SITE REPAIR SITE
000 :: �'
SYSTEM SPECIFICATIONS: TANK SIZE GAL./J PUMP TA'NK/ GAL. �-
I TRENCH WIDTH " I f' ROCK DEPTH (1 LINEAR FT.
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lITlICD l✓ 1 `" I W LP -A
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REQUIRED SITE MODIFICATIONS/CONDITIONS: 1�---k1��- C_..0,5T�r- / D-�_
IMPROVEMENT PERMIT LAYOUT
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Y
C:1~I L) EC44
"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:
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AUTHORIZATION NO. 2213" � OPERATION PERMIT BY: DATE: �!
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE EM DESCRIBE BOVE 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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME m i • Sqa:% ig ma 4. PHONE NUMBER � 61 e- 1 2 31
ADDRESS qWt ?- 6U,,.6 12J W i . a?70_6(, SUBDIVISION NAME
(Tas g 46 l m a't. - 911— S1(o - Ce l ( 5 7'7 - $101 ?") LOT #
DIRECTIONS TO SITE (o 417 4 • (..1I S61 - T• Ri -2e-4, ' O'Luk Fes- 0, � Lila mul LL CL
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DATE SYSTEM INSTALLED&,L 405 NAME SYSTEM INSTALLED UNDER Sum rj
TYPE FACILITYFACILITY Durr NUMBER BEDROOMS NUMBER PEOPLE SERVED &D
11
TYPE WATER SUPPLY Cbuwi SPECIFY PROBLEM OCCURRING 'do•�1! ULL, W YF1�uh
DATE REQUESTED 7 - 4q) 3 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, Aid that I understa IlagiAspoprsible for all charges incurred from this application
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193