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249 Hobson Drive Lot 23, Section 1Pertnittee's -- DAVIE COUNTY HEALTH DEPARTMENT Name: ��� %.'-4'' ,�r��l�~ �'v `� Environmental Health Section PROPERTY INF RMATION P.O. Box 848 ,1 = Directions to property,= G am%/ 1'/1 1�4ocksville, NC 27028 Subdivision Name: * i - : Phone # 336-7518760 3 `/ !�•, ._.l �.• ,.{.. Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - — AUTHORIZATION NO: t. °. 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) 1 r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. FNVTPr)NMFNTAI 14PAI TN CPFCIAI ICT r)ATF ISSI IFF) RESIDENTIAL SPECIFICATION: BUILDING TYPE /V COMMERCIAL SPECIFICATION: FACILITY TYPE # BEDROOMS e2._ # BATHS # OCCUPANTS l GARBAGE DISPOSAL: Yes or No # 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 = I- , ROCK DEPTH / LINEAR FT.'S-1—� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "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: ................... l%� J 154 1C 25 r'e 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 SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) �/l,✓ '-'7©5 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION • APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME_E2 ��'� ���f l�C� C-) PHONENUMBER _ C � �� � ADDRESS % �'-f-]� a /� D SUBDIVISION NAME LOT # 1 DIRECTIONS TO SITE �--o �Sa r �. LJ ,r I -•->G - % c,J s f-" Imo--` �''r DATE SYSTEM INSTALLED / a S' NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY a L?,�SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and tJ�at I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 /