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148 Sparks Rd � ��ic�n,�� -��.s- �_ : _ . .. .� .. �� !6� •!' Pernutte��s .,� � ,, DAVIE COUNTY HEALTH DEPARTMENT �d' � -� ,� Name: «�� - --�'L��+� Environmental Health Section PROPERTY II�TFORMATION �`'�� !� t14 �� P.O. Box 848 •Directions to pmperty: �� ~� � �� - Mocksville,NC 27028 Subdivision Name: .1��f..l.L'i� !�-�` �(,1�'r�1 i'�L: fI� ��i Phone#: 336-751-8760 _ , Section: ' Lo[: (� AUTHORIZATION F'OR 1':.�? . �Y`;� ��t�� on1 � WASTEWATER Tax Office PIN:# _ ; ,t� SYSTF,M CONSTRUCTION AUTHORIZATION NO: +� � �� A Road Na�e: ��1'"� 14 �' Z�p.'�,�ft,�,?{,� **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 Forn�/Authorization Number should be presented to the Davie Counry Building Inspections Office when applying for Building Permits. (ln compliance with�icl�11 of G.S:Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ;��~ ,� � �" �i�JJ I� �� DZ IS VALID FOR A PERIOD OF FIVE YEARS. �V '� [ T� *"""EN I b M A[.HEAL�'HSPECIAL ST D I SUED � � - . RFSIDENTIAL SPECIFICATION:BUILDING TYPE��v#BEDROOMS�#BATHS�#OCCUPANTS � GARBAGE DISPOSAL:Yes or No ;�__ - COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFC #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE � �� TYPE WATER SUPP[,Y�� DESIGN WASTEWATER FLOW(GPD) �O NEW SITE REPAIR SITE � - �� SYSTEM SPECIFlCATIONS: TANK SIZE GAL: PUMP TANK GAL. TRENCH WIDTH �� RfjC'IIC'IIEPfR' LINEAR FT. `�� o�Ex � ��iJ Ti o�1 'b�c. � �5?0 ��c��GTtvr� S�Sr�.FM- REQUIRED S1TE MODIFICATIONS/CONDITIONS: �� `�' ��71�)1.171►�1 V ' ��P �O� O� 1'41.7P �-�►JL� �c.�i" ��/Gki� (�t)TGJ 1� . v�l G�-L IMPROVEMENT PERMIT LAYOUT 1 . -"75 L�Li� . � ��E � �— _ . � � M�`, R' ' _ 2? F p;�� f`��`�`�- � � 1►��5 7 ��c�Jr rt Et� . ��D � D_Ev�ct..`AN o�i� ticrr *'CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM . BETWEEN 8:30-9:30 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMTT '� SYSTEM INSTALLED BY: �.�IE �� . : . AUTHORIZATiON NO.�OPERATION PERMIT BY: �/ DATE: c7 `��I��_ ��THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE W1TH 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. OCHD Ob02(Revise� .-�: _� (�� N- 7 ;�� ; � ,,� . . �L1 . �-�` � DAVIE COUNTY HEALTH DEPAR�ENT � � � � `1 f J � ��'� Environmental Health Section D PO Box 848/210 Hospital Street Mocksville,NC 27028 N�� j ZQOZ � 5'�,� 3� z�- S7 g y Phone: (336)751-8760 V � � �nRONMENTAL HFALTN ON-STTE WASTEWATER CERTIFICATION F R D LLING �v�Ecou�tv (Check One) REPLACEMENT o REMODELIN RECONNECTION � Name: r . � Phone Number: / / �✓�`��/ (I�i�� Mailing Address: � � .�,7� �v�� (Work) 1 �� Detailed Dir To Site: � ' //l /� /LS ' •/S ul'4 vJ , — t� Property Address: � 7� ��c��S � �0.7 p Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: Gl� Type Of Dwelling: �� Date System Installed(Month/Day/Yeaz): l.�X Number Of Bedrooms:�_Number Of People:� Ls The Dwelling Currendy Vacant? Yes 0 No�( If Yes,For How Long? i � Any Known Problems?Yes 0 No� If Yes,Explain: A�-d `^� Please Fill In The Foll wi Inf ation About The New Dwelling. � 3�+� 1��o� Type Of Dwelling:� Number Of Bedrooms: Number Of People: � Requested By: Date Requested: .� O - ignature) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ �- � ? 4 3 �' Comments: (–��``�')`` r�� c�l.�� I�3'D� Environmental Health Specialist Date � "�The signing af this form by the E ironmental H th f is in no way in nd ,nor should be taken as a guazantee(extended or limit t the on-site wastewater system will function properly for any given period of time. Payment: Cash❑ Chec Money Order❑ # Amount: $ -s� `— Date: ` c7'�-- Paid By: Received By: Account #: � v�� Invoice #: � -�--3 � � � x , �, : � . �1 _ � � 8700000008 a� �GC� � � �� . � _ : � G � � , '�.. � � .,__ : _� � ; _ , , , � _ �i �c.s ,�q �_ J • i ( � , , � `-forn2 � _ /�_�� r G � �' ti��pds�d' �"��.l,d_ 4 8_______ ___ ___�_________.___ __ . _ _ _. . __ � . _ _____ __ ___1__ _5 __ ___ __ ._.. _ ___. __ ._ _ ___ .. _ _ � _ . R ..,,..,