437 Redland Rd y' e�a y��,v.:: .,,i.-� orPy,rt. ��'z:��''�-< r �'x' !'-`-w:.} ;y������' '4K;.-.;: 5 „-.,,-.r;o--.,.�'r°y., 1 A°,;_.�..'w �.�,.'��,•..,,r.'",�„i.�.,y��'.-..,�, .�.�i�x;; , :�•.��,..1 �y....,:._.� r .�� ,
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� Permittee' ,�,�//. DAVIE COUNTY HEALTHaDEPARTMENT ��" �/ ?�/�
Name: ��,i' ;��. <,+� Environmental Health Section PROPERTY INFORMATION
_; •_. -: ' P.O.Box 848 .
' ��Diiectio s to'property:���-�''°.�iJ+'�j�ftf Mocksville;�,NC 27028 .. Subdivision Name:
�'��- ' � / Phone#:336-751-8760 :
,�,�( �r��c`�''_ �✓. l , Section: Lot: _
,�� -• / r� / ' AUTHORIZATION FOR
�J/''�,� f:J i /f����i�.S� ✓ 1��� WASTEWATER Tax Office PIN:# : _ -
, SYSTF,M CONSTRUCTiON
AiJTHORIZATION NO: ' . � � � � A Road Name: Zip:
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmentai Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie Counry Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
fJ' ' � 1 ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�" �`��.�� .`�~ �7 � IS VALm FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL H A�� DATE ISSUED
�
:: .; , _ _
. . ,
RESIDENTIAL SPECIFICATION:BUILDING TYPE � �I #BEDROOMS`�#,BATHS��#OCCUPANTS�GARBAGE DISPOSAL:Yes or No
t::. • '
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFC #SEATS INDUSTRIAL WASTE:�Yes or No
LOT SIZE TYPE WATER PL DESIGN WASTEWATER FLOW(GPD) NEW SITE ' REPAIR SITE !� ',
_ �, �� !�,
SYSTEM SPECIFICATIONS: TA SIZE�� GA . PUMP ANK GAL. TRENCH WIDTH� ROCK DEPTH� LINEAR FC.�C/(l
� �. . � , . . - . O . .. : - � . �tr. . . . ' � . � � � . -...� � ,
REQUIRED SI7'E MODIFICATIONS/CONDITIONS: c�R�/ /� l�/1 oL `! '(' � �� �`�C-
IMPROVEMENT PERMIT LAYOUT �
' � � � C��l� ,` 'O�/�c-
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R�e
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, � � . ' . . . . ' . . . . ' ' . ' . . . . �? . . ' � ��� . � . -
' � � � � .f . . . . � . ,. _ . ' `.�.�..r.��� '. . . . .. � � . .. ..
•"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
Bb"TWEEN 8:30-9:30 A.M.OR 1:00-I:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. -
,
.; OPERATTON PERMIT : � I
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AUTHORIZATION NO. /I/I OPERATION PERMIT BY: �" f'=� �/ � �
-S�`�� DATE:
••THE ISSUANCE OF THIS OPERATION PERMTf SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTTFI 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 WII.L FUNCI'ION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. �
DCHD 0?N2(Revised) . . . ..
. � ,
,f��Q �TV �� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
�! ', APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �
NAME J--�Il r����e 2 �nv�,-f-�, PHONE NUMBER 7 f �^ / � �J �
� ADDRESS �� � ����-� � �� • SUBDIVISION NAM� � �3' 8 S� � �
�d�-(.��n c� � �-' , LOT # ` �
1
DIRECTIONS TO SITE � ��— ��S S �nu�'� G�d cJ�- �w �-�� - �I
`� t C � ) -/�, 1�
� b � T �2� 1 a- h� �—�a s s����-,So a r�or b r��.c, 7-�'/�- ��-� �-�'7` "�
DATE SYSTEM INSTALLED �- NAME SYSTEM INSTALLED UNDER? P�.ss�t. Ja /��s'a•� Z
�
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED S
----
TYPE WATER SUPPLY SPECIFY PROBLEM ocCURRING � ,-�-�e-o d d'C
� � —� o d-I-s �.�. �t-o �+-P►�..._ � F.x.�.�.
�-n�- � �l d � �)
DATE REQUESTED 1 �-/.�r, o� INFORMATION TAKEN BY � � �
This ia to certity that ths infortnation provided is corcect to the best of m knowied e,and that 1 understand I am res nsible for all char es incuned(rom this lication. ' "
Y 9 P� A �PP �
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93
�_c�.- f'7�e�6� /-e. ��+�-P � �� l'� �� ' .S�'.s 7�"-"� :�I .