143 Pete Foster Rdformittee' f,1t� > r��,.-; �' �DAVIE COUNTY HEALTH DEPARTMENT
Name: _ . J / .�+%• ; • i r ` r . Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: "� f l� '` /'hlocksville, NC 27028' Subdivision Name:
f Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 0 0 2 5 F 0 A Road Nam �!��-�' 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)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
a,"` ;; ;� dr'/ r; +', " �',✓_. + r' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS: # 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 (GPD9, /- o NEW SITE REPAIR SITE r
� y
SYSTEM SPECIFICATIONS: TANK SIZE GAL.. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH f LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
----------
If
II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. I
OPERATION PERMIT
SYSTEM INSTALLED BY:
/90 1
AUTHORIZATION N&- PERATION PERMIT BY: �� DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. LLCC# -Z -? ( ` I'
DCHD M2 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME / / 1ct2T' If�4 c� en.r+ PHONE NUMBER
ADDRESS 1Y 3 i�-t-�t �� .S i -t^ id SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER %�` •�►dam �...-
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY—C,4
::``f SPECIFY PROBLEM OCCURRING
DATE REQUESTED 7/S d S INFORMATION TAKEN BY l9—
This is to oertify that the information provided is correct to the best of my
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1/93
-� S -,+./o ?t_- ,J -e -71— N 0
and that I understand I am responsible for all charges incurred from this application.