169 Pineville Rd a G�
ttee's /„�� D IE COUNTY HEALTH DEPARTMENT 04P!6
// ' — /f� Environmental Health Section PIrOPERTY INFORMATION
a,,_ P.O. Box 848
Dir4cti6ris to property: Mocksville,NC 27028 Subdivision Name:
y: Phone#:336-751-8760
_ ' r.:�f��• Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
-
AUTHORIZATION NO: t oy 0 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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIkONMENTAL IYEALili SP I ALIST rA E1 SUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE BEDROOMS, #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No `
LOT SIZE TYPE WATER SUPPLY�- DESIGN WASTEWATER FLOW(GPD) _: NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. .TRENCH WIDTH ,ROCK DEPTH ,r LINEAR FTC_~
` OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
�� al
P
**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: A
AUTHORIZATION NO + OPERATION PERMIT BY: DATE: C
"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.
DCHD 02102(Revised)
r
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 1_
NAME l../R�LT� C� - L� PHONE NUMBER �]
ADDRESS- ,& Re A&0j jr-.' �j SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE e
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING fl
r
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