P1788 Swicegood St DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPR VEMENT PERMIT(REPAIR)
NAME A l PHONE NUMBER
ADDRESS 7� a �- SUBDIVISION NAME
LOT# u
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING o
h
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193
�4AUTHQRIZATION NO: �� 8 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section ,. PROPERTY INFORMATION
Permittee's ---"" P.O.Box 848
Name:' .o.. Mocksville,NC 27028 Subdivision Name:V.
rT Phone# '336-751,-8760
/ one
Directions to propert Section: Lot:
,( AUTHORIZATION FOR
CEJ fJ> i✓t/i p41 noS WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
Road Name: Zip:
**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 Form/Authorization Number.should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11.of G.S.Chapter 130A,:Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD.OF FIVE YEARS.
ENVIRONMENTAL HEA TH SP'-CIA IST:. ,BATE ISSUED
♦n.tr.• I-r .. - -�f' E1..,_..>:..i, hirrii dr s :i'wyV'Y ;.,�v, '�
~" % i DAVIE COUNTY HEALTH DEPARTMENT ,
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
„ ermtlt e's -�- f
`Name: i >.` % Subdivision Name:
Directions to property. +`� �r�>�r �` Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: Zip:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130.A,Wastewater Systems,Section:1900 Sewage Treatment and Disposal Systems) ,
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE r
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPEChACI_ST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMITBEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE, ^
#BEDROOMS, #BATHS T#OCCUPANTS GARBAGE DISPOSAL:Yes or No
a
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 171 ROCK DEPTH�LINEAR FT. I�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLU ITER* *RISER(5) IF 612 BELOW FINISHED GRADE*' ,
`E e�
6 .Ira 1110
i
**CONTACT A REPRESENTATIVE OF THEDAV COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THI&$YSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-I P. ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)6-y4*6 HXXX
(336)751-8760
OPERATION PERMIT
SYS STALLED BY:
N
,.
AUTHORIZATION NO,�OPERATION PERMIT BY: ��%L1 DATE: CY G 1
**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 SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)