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,errtld�e's�,' ; : DAVIE COUNTY HEA
� P ,. LTH DEPARTMENT 1�" ,����0
Name� E �� ' ' ''� �` �` ' Environmental Health Section PROPERTY INFORM'ATION �
` � P.O. Box 848
Directions to property: `� '' � '` Mocksville,NC 27028 Subdivision Name:
" Phone#: 336-751-8760 �
�`'•' ` t Section: Lot:
' AUTHORI7.ATION FOK
� WASTEWATF,R Tax Office PIN:# -
, SYSTF.M CONSTRUCTION -
AUTHORIZATION NO: ������ 1� Road Name: � ��r j'" �'� ' �.► Zip:
**NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pennits.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
� � r � . ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
� ` � � ` �' IS VAL[D FOR A PERIOD OF FIVE YF,ARS.
t(���, _ � �•. � , '�; �,��t'f
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ENVIRONMENTAL HEALTH SPECIALIST DATE 1SSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEllROOMS .] #BATHS #OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFISHIFT #-SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE �f• '. TYPE WATER SUPPLY �(� ' DESIGN WASTEWATER FLOW(GPD)� !� NEW SITE REPAIR SITE Y
SYSTEM SPECIFICATIONS: TANK SIZE �X�����L. PUMP TANK�GAL. TRENCH WIDTH ��!" ROCK DEPTH��-'� LINEAR Ff. !-��� `
� ".�`"� �i�0 �< f-��t,i( -I C"�t�'�`
OTHER ,
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
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IMPROVEMENT PERMIT1LAYOUT =� .t- ^C �f'j G
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT c 1 !� _ )j �/
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AUTHORIZATION NO.-'�l �� ^ �OPERATION PERMIT BY: �- � � �1 ' ���' ^ � � DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIB D 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 01J02(Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �Q•1`� �OGP-� PHONE NUMBER ��S�'' ��D��
ADDRESS��� �G1111�I'► G �Y) SUBDIVISION NAME 1�I1�-
LOT #
DIRECTIONS TO SITE -� YVJ'livJa�7➢-� �c� •� �fJC�vl�7� �i
DATE SYSTEM INSTALLED����NAME SYSTEM INSTALLED UNDER
TYPE FACILITY �Z-�S NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY INZ'iL� SPECIFY PROBLEM OCCURRING S�Wa�1� l S
�ur�'-c�r��c, �m �4'1�� bGc�l� N�� , -�-r�i�-e� �ok �FIvsG���� as Fas�"
DATE REQUESTED�� I� INFORMATION TAKEN BY /T�l�
This ia to certify that the informetion provided is conact to the best of my knowledge,and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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