335 Riverdale Rd ,� : ... _ .: , . ,::,. .. . _, .. , ,., . -, . ... , : _ .,
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Pernuttee's ;,�/� DAVIE COUNTY HEALTH DEPARTMENT 7i��
�—Aidi[1Cr �C/t��+�� !�� Environmental Heaith Section ' PROPERTY INFORMATION
P.O.Box 848;
Directions to property: ��`�4�� 1 ��/rf!"����� Mocksville,NC 27028 Subdivision Name: �� �- �_- �S .
�,�%%���%:�'i/�s'`�� ' Phone#:336-751-8760
<'= Section: Lot:'
AUTHORIZATION FOR
� WASTEWATER Tax Office PIN:#
` SYSTF.M CONSTRUCTION - �
AUTHORIZATION NO: ���� A ' Road Name: ` Zip: '
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the bavie County EnvJronmental Health Section prior
to issuance of any Building Permits.This Fom�/Authorization Numtier should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln complianc�with Artide U of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/ /% � �• �
r�� /� ' j � 1 , � ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
il��J ; {��'P �",1 �—,,J�� �—.�� IS VALID FOR A PERIOD OF FIVE YEARS.
ENViRONMENTAL HEALTH SPECIALIST - DATEISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE}� #BEllROOMS�,#BATHS�#OCCUPANTS .�J GARBAGE DISPOSAL:Yes or No
.
COMMERCIAL SPECIFICATION: FACILTI'Y 7'YPE #PEOPLE � •-#PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No '
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD� NEW SITE REPAIR SITE�,
/,� ' � � �i�.' j�t.� ''
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK AL.TRENCH WIDTH��%� QCK D�PTH � LINEAR FT.��1 1
`` `�- '''_. ,� ��i' -�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
� IMPROVEMENT PERMIT LAYOUT '
. : I
. . ' . � . . . . . . . . . .. � . �Mtis.: , .. '
. . . �. � .. . . . . ' � . � .
f. . . . . . ��., . � . . ��.,".'h. � .
' . . . . . . ... � � . � . � _ . . .. . .. . .
•'CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 830-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. .
OPERATION PERMIT . �,�(
SYSTEM INSTALLED BY: �U'G ' � ,�
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AUTHORIZATION N0.�����PERATION PERMIT BY: DATE: ��G�
��S
s«�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTfH 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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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�' �� ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
- , �� ���
NAME 1� /►� �G �`�-v�� PHONE NUMBER
ADDRESS �� �{,�.�.•�� I�s�` � SUBDIVISION NAME
.
�C�-S �/ ��� , � L— LOT #
DIRECTIONS TO SITE �J/S � � E'i /`�--f., G�iv�► "°�ac9-c,� ��`G-S
,d6� � /"''��/����/b r"'�`,,4'�-, E� s/�
DATE SYSTEM INSTALLED �a� NAME SYSTEM INSTALLED UNDER �`'�'�Y" a "S�"e�4
�' 6�io �
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY C~�w•�n.`�-c� SPECIFY PROBLEM OCCURRING ��� �► ��
he-�-.�- .��-�Q� � � ��-�-
DATE REQUESTED y� INFORMATION TAKEN BY �
This is to drtify that th�iniormation provided is eonaet to ths best of my knowled o,a�nd th�LLuaderstand I am ns , sible for all arpes ineunsd from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT` �� •
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