119 Sunset Dr ., _
. , . . , : ... : ,, . , ;., : •,-. _ . , , . , , . •,.,,
Permittee's�,�! DAVIE COUNTY HEALTH DEPARTMENT 0���/� d�� �
`Name:';J s,��.���� (j��✓/�,�"� ' Environmental Health Section PROPERTY INFORMATION
•-' P.O. Box 848
Directions to property:����.r����.�'"�e� �r Mocksville,NC 27028 Subdivision Name:
, 51-8760
/ Phone#:336-7
��-�C�.t?�,��� rrt� �r'r�.��' Section: Lot:
AUTHORIZATION FOR _
WASTEWATER Tax Office PIN:#
SYSTF.M CONSTRUCTION - '
ALJTHORIZATION NO: �� �� p Road Name: ' Zip:
**NOTE**This Autharization for Wastewater System Construction MUST BE ISSUED by the Davie Counry Environmental Health Section priar
to issuance of any Building Permits.This For►n/Authorization Number should be presented to the Davie County 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)
., :'
��z, � r` ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
' .�7I'�" >1�/`�,�/,r��r�,/./'�/"�}�T _�/� IS VALID FOR A PERIOD OF FIVE YEARS.'-'
ENViRONMEN'I�AL HEA�PECIALIST DATE ISSUED `
, . .,
RESIDEIV'fIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS�_#BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No
�,
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No �
LOT SIZE TYPE WATER SUPPLY_� DESIGN WASTEWATER FLOW(GPD)��/ NEW SITE REPAIR SITE /�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK' GAL. TRENCH WIDTH 3G ROCK DEPTH "��LINEAR � ��
' , a .
OTHER '
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT .
_ '
. . . �:;4,
, , .
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r _.
*"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. ;
OPERATION PERMIT
SYSTEM INSTALLED BY: r� r/�'L
AUTHORIZATION NO OPERATION PERMIT BY: "/ �, DATE: �� � ��
r����
*'"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTTH ARTICLE 11 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
. DCHD 0?!02(Revised)
���� . L
' ,;:,. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
» I APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) M
��. / � 1
NAME i ��-- �-- �� �e- Law Q pHONE NUMBER < ��=5`�� y� �
, ^ '
' .�-.�,se�t D�2� ✓.e.. � I
ADDRESS � l 5 S SUBDIVISION NAME
�y...o c Ccs d-1 !/A. �
LOT #
DIRECTIONS TO SITE ��� an l� � �-e�o� S ��° r- -swh-�- �� �
�
��e��- � l,J 1�a ,��.�„�-,. o.,,.;r- ��� �
7 �
DATE SYSTEM INSTALLED �d+► NAME SYSTEM INSTALLED UNDER '
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED 3
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRINGy� ,��a�� �'X ��a-
` � I- �
r,-�-e._� .�.e..l � �.� C�s -e-�—��2�►-.- �-�r-�._ ����,;�. �,yo �
DATE REQUESTED o�- INFORMATION TAKEN BY_____�� •
This Is to certify that the information provided is conect to the best of my knowledge,and that I und�rstand I am nsponsible tor ail charges ineurred from this application. ,rt
'h4
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93