242 Turrentine Church RdAle:n-
ittee's DAVIE COUNTY HEALTH DEPARTMENTNme:t�,e.� % Ose Environmental Health Section PROPERTY INFORMATION
;�P.O. Box 848
Directions to property: �`�>/'�e ,,nom +CV&ksville NC 27028 Subdivision Name:
Phone #: 336-751-8760
bi
Section:_
i AUTHORIZATION FOR
r WASTEWATER
Lot:
Tax Office PIN:# -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: A 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
-' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
J_, IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPEC ALIST r DAVE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE /,/ # BEDROOMS 0— # 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) �l/� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH,,K G ' ROCK DEPTH LINEAR FTr f ,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
1
**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.
I OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO.� OPERATION 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 SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
3 02 2
ermiftee's
: !
DAVIE COUNTY HEALTH DEPARTMENT
00 Name ;22/ r- L
DSS
Environmental Health Section
PROPERTY INFORMATION
/P.O. Box 848
Directions to property:
(12cksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section:
Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: r_, #0 •" A 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 Pemuts. 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)
x z,�� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
{' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE A T ISSUED
+11
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 0- # BATHS l # OCCUPANTS &_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
01"'7 ._%
LOT SIZE TYPE WATER SUPPLY f DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH +' ROCK DEPTH / LINEAR
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
1�
"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:
AUTHORIZATION NO. �� l Y«`Z
� OPERATION PERMIT BY:
"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.
ncnn ovoz (Revised)
'0
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) C�
NAME 1 Cfi4 e..L � S e PHONE NUMBER / 7 9 / �J L/ 9 7
ADDRESS C7'-7 a ) tett C�_ r` SUBDIVISION NAME
oc�S✓IIIA LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED -� S NAME SYSTEM INSTALLED UNDER T
TYPE FACILITY NUMBER BEDROOMS �— NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
/ I / l 00
4 � � �-- no � a- he n�-c .Qe � /��� - D � c � �z �i Q- e cis �7"c� a L .L t N{f 0
DATE REQUESTED o INFORMATION TAKEN BY-0-
This
Y0This 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
Re,. ,roa /+