The URL can be used to link to this page

117 Willie Cook Dr �,�emrnii��tee's ..:, r:;r-, � DA y�IE'CO.UNTY HEALTH DEPARTMENT Name: '��fr--� �- %�� ' �� :' �!,�,�• /f r� Environmental Health Section PROPERTY INFORMATION F_, r; � ;'� P.O. Box 848 l,"�0 �_-2..5�_ �� Directions to property: /�� -�'` � �'� � � j:J�• �qocksville, NC 27028 Subdivision Name: -` ,;,'� ;F f _� � Phone#:336-751-8760 � , ; ��`�;s l + '"=' •,'� - Section: Lot: . AUTHORI7,ATION FOR WASTEWATF,R Tax Office PI :# �t 4 � �,� SYSTF.M CONSTRUCTION /�� '/��rj��-�-,fj-�� c_:r�.w �.,» �� (:l1(1 K�� f 1�,� AUTHORIZATION NO: A Road Name: Zip. **NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior to issuance of any Building Permits.This Fomi/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) ***NOTICE***THIS AUTHORI7ATION FOR WASTEWATER CONSTRUCTION , + �.�<-•' r."f'`� ' ' � r .� IS VALID FOR A PERIOD OF FIVE YEARS. ENV[RONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE � #BEllROOMS .�'` #BATHS � #OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPC,EJSHIFI' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FI.OW(GPD) � � �� NEW SITE REPAIR SITE jA � / J �r SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� /ROCK DEPTH /� LINEAR FT. �\��''� � OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ' � IMPROVEMENT PERMIT LAYOUT ��,..�----�"""�"""' ` �� **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPA ENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00- 130 P.M.ON THE DAY OF AL�►,ATION.TELEPHONE#IS (336)751-8760. •' l� , � , OPERATION PERMIT TEM INSTALLED BY:_�l�=�^�� \ - ��, � , ', ,---•^------ - �.' AUTHORIZATION NO.L��=��-`—OPERATION PERMIT BY: DATE: � O **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T HE SYS M E IB QABOVE H EN INSTALLED I C MPLIANCE WITH ARTICLE I 1 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 01102(Revised) � . w i,. �. "w . ,. ' '. . •.. , _ .. .: �..� . i .... ��rsa�. ..t, e .v- e T�) � vf , .. �. ". " .TT '! . ..- �3`'.� . ,.. , . . + .. ^f�. .. ., .- . ' ' .' •�.. � ...- �£t:��r"Y� � . . ..'... . .. ar 1 �y. . . . �. .., . .. e-�...- �<." �.a*�8k ;Pk+� ..n�' ..' , . , ., .� � � . 4> r�� F �"!r�� . . . . i : . ... ��` �' ' `� DAVIE"COUNTY HEALTH.DEPARTMENT r s v_ •�r�� " �r �� - .; , �� ame:�� f�_ � :'�> �'�t .� r�'�"�� s'��`� ; Environmental Health Section PROPERTY IIVFORMATION � _ . „ -, 2 �.A .�� .�,� .. ��.^� � ,, . :.. ., = P O:.Box'8'48 ,. �, . . '' ,P7 2., w,�" °,"'Directibns E"aproperty: €�a a � ��``:, ' �� ,�,�}* Mocksville, NC°27�28� 'Subdi�ision Naine: �� '� � '� Phone#: 336-751-8760 ' ��. ' : � � � ^ .�"'!�� ., �"�',; ' Section:� I,ot: . s �-,s ` � AUTHORIZATION'FOR . ' � _. ,; "� ;:'� ,, , , WA5TEWATER "< • „�- . x SYSTEM CONSTRU.GTION Tax Office PIN:# � r - � �t � j1'� �',��`�r�`�ur��`L�� ! � ;��;c � AUTHORIZATION NO: � �� A ` ' Road Name: Zip: '} ,. . • ` � **NOTE**This Authorization for Wastewater System Construction MUST BE,I:SSUED by the Davie County Environmental Health Section prior - � ' ro issuance of any Building Permits.This Forni/Authonzation Number should�be presented to the Davie County Building Inspections Office when applying for Building Pennits. � ` (ln complianL•e with Article 11 of G.S:Chapter 130A,Wastewater Systems,Secjon.1900`Sewage.Treatment and'Dis,posal Systems) � • � � �� .�'` :` � .. , , , .,• ._ _ ***NOTICE***TH S . ONSTR ;;.,. _ I AUTHnWZATION FOR WASTEWATER C UCTION f + • � `� ':�r'� :°,Y ,• p t :'b'�" : ' ,.� IS VALID FOR A PERIOD OF FIVE YEARS. �r .. - � ° . ENVIRONMENTAL HEALTH SPECfALIST. _ DATE ISSC�ED , , RESIDENTIAL SPECIFIGATION:BUILDING TYPE� #BEllR�OMS�'� #BATHS � #OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS , INDUSTRIAL WASTE:Yes or No . COT SIZE TYPE WATER SUPPLY ! ` DESIGN WASTEWATER FLOW(GPD) . � � NEW SITE REPAIR SITE A�`�r� ' :� , . . . , _=��A � � . ��? SYSTEM SPECIFICATIONS: TANK SIZE� GAL.°PUMP TANK ' GAL. TRENCH WIDTH � ROCK DEPTH /� LINEAR FT. ��b% � "" .. . . . . i.. - � -� �. � � ��. � , ' , . . � . OTHER .. « <. . ��, ,. �, , _ ; REQUIRED SITE MODIFICATIONS/CONDITIONS: � " ' • �., . IMPROVEMENT PERMIT LAYOUT , ` `: �'�""`�'� � , • - � I` : ' . , { . . . � , �. „ . .- . ;,,,,, ,i . , . � . . I ; ` ' . � . . , � , „ � M�+�+r.M+�Mw! • . «..,^t.•, � . � ' . . , , � . , . . . � , ` , _ , . ' .. . . � . .� . , - ' ` 11 . .. . � .. � • . � . ' .. . � �.. , � _ _. . - . . .� s . . .. , - , ' . , . ; � � � . � ... � .. **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPA ENT FOR FINAL INSPECTION OF THIS SYSTEM � BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE Df,�Y OF Ar�LJsATION.TELEPHONE#IS (336)751-8760. ,.. ', . . .� ,�(�fj, , �� OPERATION PERMIT ' ��, j„ /►,(}-rf t �r�«�rt �r.�� ,�' . EM INSTALLED BY.: . ,� , ` , , - . . � . , . � . �� ' �, '� � • t , . . �� . - � _ �L�-�-T ;r � g ,�: AUTHORIZATION NO. I � OPERATION PERMIT BY: ' ! Dq�: � C� ••THE ISSUANCE OF THIS OPERA'I'ION PERMIT SHALL INDICATE T THE SYS M DE IB D_ABOVE H N INS.TALLED I�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 0?102(Revised) , - ' . ��,� . . . .. ^ .� �� - �� . . . .. � ��. : � . - . . - . � -� ". . . . . .. .. . . . , ' _ . . ' � ' . , _ , .. ...,. . ��. ' . - - .. � ''. .. . . � . , : . : ' � . , . . ; . � .. � - . . �� . . r� . � . . �. , . . _ sgs. . .t,• � � •. � � ,.. . � ' � . ( • � .. ��•� ' . . . • ' " .r . . ' . � , .. .. z � � .. � �. 3 .. � . � . ' ' � � � � � .