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Natu�:�.r Environmental Health Section PROPERTY INFORMATION
. r'�' P.O.Box 848 p
Directions to property: ����Ll�' �rQ >�`"i'}f`��"� hQocksville,NC 27028 Subdivision Name: 1
��)� Phone#:336-751-8760 3
Section: Lor.
AUTHORIZATION FOR
_ WASTEWATER Tax Office PIN:#
SYSTF,M CONSTRUCTION � �
AiJTHORIZATION NO: ������ A Road Name: � `'� �V��Z p� �,��"�[�
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Bnilding Permits.This For►n/Authorization Number should be presented to the Davie County Building Inspections
Of�fice y6Tien app��ng for BiI'iTa'ittg-�rrnits.
(In complian�'w'f�Article 1 of G.S.Chapter 1 A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
°� ;�f � �' ,/ �-- ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f �r� � L' � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRO MEN .EkL'i'N�SPECIA lST DAT IS �ED
RFSIDENTIAL SPECIFICATION:BUILDING TYPE �� �#BEDROOMS�_#BATHS_�#OCCUPANTS�_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILI7'Y TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY�<<-L-' DESIGN WASTEWATER FLOW(GPD)� NEW SITE REPAIR SITE � '
.•r �� , � �
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH �� LINEAR FT. ��`�
OTHER � �✓Tr^I`�t-'i/�l.t"` � �
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REQUIRED S17'E MODIFICAT[ONS/CONDITIONS: ��Sr4�"�"' a^'J C.aJ��J e ��� ) f*� �-1:; 1
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IMPROVEMENT PERMIT LAYOUT � f�tlJ�
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BEf WEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMTT S�L� �
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. �4 OPERATION PERMIT BY: �
'■THE ISSUANCE OF TH1S OPERATION PERMIT SHALL INDICATE THAT THE YSTEM DESCRIBED AB HAS BEEN INSTALLED IN COMPLIANCE
WTTH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATM AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR AN GIVEN PERIOD OF TIME. ��'- � 9 g 1900 D 7'r
ncxu ow2 c��;ua, � �n.�l �'— T g/�
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��� Pe . tt�'s �'�� `'�-DAVIE COUNTY HEALTH DEPARTMENT '�n`� ���-''S
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Na�r�„��''�'-R.' Environmental Health Section PROPERTY INFORMATION
_ / , � P.O.Box 48 D�.
Duec�ions to ro :L/L• ,I c' ' `. ��;�"..- , -i Y'
P PertY:' '� � Mocksville,N� 028 Subdivision Name: 1
, ; i' Phone#:336,-751�8760
� � ""� • .Section: Lot: �
- AUTHORIZATION FOR
, � WASTEW�TF,R � Tax Office PIN:# - -
SYSTF,M CONSTRUCTION
0�2�G0 a :�,�. �_v(✓��--�`''P:� ' 'i "�
AUTHORIZATION NO: A . Road Name: Zi .-- ,.---'
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**NOT'E**This Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
' to issuance of any B�iiding Perrnits.Thiti Forni/Authorization Number should be presented to the Davie Counry Building Inspections
-� Office v�tien apply,�ng for Buficttttg-P.,ermits.
(ln complianc�wi b Article �i of G.S.Chapter 13�A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
' � �`� �� � �"' ( •-� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� ; � �..� 1t-� IS VAL[D FOR A PERIOD OF FIVE YEARS.
ENVIRO�f .ENT � H SPECIA ST � DAT�ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE �.t-lJ •#BEllROOMS�#BATHS / #OCCUPANTS�_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
'LOT SIZE � TYPE WATER SUPPLY ��L"�L DESIGN WASTEWATER FLOW(GPD) � � NEW SITE REPAIR SITE �
. . " 'r ' f
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �-'W ROCK DEPTH ��• LINEAR Ff. ���
-Q��, � ) 1_� /t�' ��
OTHER I <I,.'-��T�—I�l�V.J�CX"' �Ci�� 1'. -
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REQUIRED S1TE MODIFICATIONS/CONDITIONS: , �
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� IMPROVEMENT PERMIT LAYOUT �rJ')� �. `
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FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL B6'TWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT ��,L�
SYSTEM INSTALLED BY: """
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AUTHORIZATION NO. �A OPERATION PERMIT BY: ` I -
*•THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE STEM DESCRIBED'AB V AS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECI'ION.1900"SEWAGE TREATME AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
* GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR AN GIVEN PERIOD OF TIME. ��- �Ef 9 � U UD p 7 9_y
ncHn oyoz�����a, _ ' � ,, .I _'�" yg/ �
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_.. �, . DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ���-�� ��r�"�J PHONE NUMBER
ADDRESS ��� �r�"�� � SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY fi� NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING S�cS���'— ����� �
��vrn��r IS �CIC��C� �
DATE REQUESTED INFORMATION TAKEN BY
This is to oatify that th�information provid�d ia cortect to the best of my knowlsdgs,and that I und�ratand I am r�sponsibie for all charpes i�curred hom this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1 J93