309 Spillman Rd :,; , ; : : . .
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DAVIE UNTY HEALTH DEPARTMENT
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�'' 1�!�� `�-���?✓��r=���_ Environmental Health Section PROPERTY INFORMATION
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Directions to property: /�-' !�' J`'.%''ri''�.1'f>/''��ocksville,NC 27028 Subdivision Name:
�^ '1 �? -. ,- ...,�,� /'��`" -� �-.� . 4`: Phone#:336-751-8760 '
/`.e��,i � ,� /f�`%�r'%�'`i�, i% ,��-E Section: Lot:
) �; E AUTHORIZATION FOR
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����.�,�;� " SI�STF,M CONSTRUCTION
AiJTHORIZATION NO: ������ 1� Road Name: Zip:
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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 Perrnits.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
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:.- �` �.�:,- ` � �f ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�'�``�'��_��"' ,. �r-�'�r.%��G<�'�r� � �,�/G� ,�c"�„LI�ALID FOR A PERIOD OF FIVE YEARS. x,^;
ENVIRONMEN ;A�L HEALTH SPECIALIST DATE ISSUED '"*w,�^'3
RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEDROOMS�#BATHS � _#OCCUPANTS��jGARBAGE DISPOSAL:Yes or No
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COMMERCIAL SPECIFICAT'IO�N�,^�'�/CL[�'��rY�� #PEOPLE #PEOPLFJSHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
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LOT StZE TYPE WATER SUPPLY Ca DESIGN WASTEWATER FLOW(G D � v NEW SITE REPAIR SITE��
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK �' GAL. TRENCH WIDTH_-�L ROCK DEPTH� LINEAR FT.���
(4 1� r �.,.
OTHER -��,�" � '1 � �''3_ `}`` ,, f"
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REQUIRED SITE MODIFICATIONS/CONDITIONS: �
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPECfION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMITl � )')/J � J�Jn /
�/ SYSTEM INSTALLED BY: �/� ,// ��U�//J!�'L
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AUTHORIZATION NO. / PERATION PERMIT BY: DATE: /
*'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 SATISFACTO�iILY FOR ANY GIVEN PERIOD OF TIME.
DCHD O1J02(Revised) �,�O Q^' �
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� � ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION '
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
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NAME i� PHONE NUMBER �u16 ����
ADDRESS�T � ` /? SUBDIVISION NAME
,i��L'���/ E' .�I�/�i . LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLEO � NAME SYSTEM INSTALLED UNDER / � �'
TYPE FACILiTY NUMBER BEDROOMS o NUMBER PEOPLE SERVED
TYPE WATER SUPPLY � SPECIFY PROBLEM OCCURRING � �!_l
DATE REQUESTED � � INFORMATION TAKEN BY ���/
This is to artify that th�information provided is correct to the best of my knowiedge,and that I underoWnd I am responsible}or all eharpes incurced from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT //'� •
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