156 Sonora Drive Lot 8PeriviaeresDAVIE COUNTY HEALTH DEPARTMENT �2 � 1 .5+:
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Ilame: ;' T, ? �:� Environmental Health Section PROPERTY INFORMATION
f ('" P.O. Box 848 /
Directions to property: / �`�'`� ��'� . 1`4ocksville,;NC 27028_ Subdivision Name:
:Phone #: 336-751-8760
Section: - Lot:
71AUTHORIZATION FOR
—WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# - -
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 FornVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In comRliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
i�H&�T
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE =11-1= # BEDROOMS_ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes orNo
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�ROCK DEPTH`/>I LINEAR
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"�-- — d
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.
INSTALLED
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 I I 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.
ncHo oyoz (Feevised)
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ADDR
DIRECTIONS TO
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
SUBDIVISION NAME
LOT #
%W J_ 1
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY 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 that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93