1283 Calahaln RdV � r . � , � . , � � � . � � .. , . . � � � . - . . _ . _ . - ., . �;��,.
r�ermittee's r;�r q, f DAVIE COUNTY HEALTH DEPARTMENT
Name: _�.-'? �,{ ,��� �'���%d"'o� Environmental Health Section PROPER II�1k'OR ATION
.. �: ; � ' �? ,� P.O. Box 848 �0'l�� � (� _c� y
Directions to property: �r^�. ��-.� � r;�F.�1,�r;-�' ���- (• ]�qocksville, NC 27028 Subdivision Name:
� f?-jf , ..; '^ ; ��, l ;�' �,,; a Phone #: 336-751-8760
, � Section: Lot:
r�-, , f'1�! i AUTHORI7.ATION FOR
�> - � �' „� � `/` �,✓_. �' ,�,,�; ' y „'!., , - R'ASTEWATER Tax Office PIN:# - -
�SYSTEM CONSTRUCTION
,/ �'� '� r": ,r i� +d' '�
AUTHORIZATION NO: ���� A: Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Sec[ion prior
to issuance of any Building Permits. This Forn�/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Perrnits.
(ln compliance with Artide 11 of G.S. Chapter 130A, Wastewater Systems, Section .] 900 Sewage Treatment and Disposal Systems)
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ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
***NOT[CE*** TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
RESIDENTIAL SPECIFICATION: BUILDING TYPE ��`� # BEllROOM� # BATHS �# OCCUPANTS ii GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL WAS'I'E: Yes or No
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LOT SIZE TYPE WATER SUPPLY �+�! d/DESIGN WASTEWATER FLOW (GPD) S.,� NEW SITE REPAIR SITE �
�
SYSTEM SPECIFICATiONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �,�1 �` ,ROCK DEPTH �� / LINEAR FT. �`�'-v'
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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**COI3TACT A REPRESENTATIVE OF THE DAVIE COUNTY EALTH EPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM '
'� BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 130 P.M. ON T E DAY INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
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'ALLED BY:
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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.
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
�' �-- q�.. SS�S
NAME '� Z-- � SC S�d � PHONE NUMBER �l
ADDRESS �� a 3 ��T�/f 4-�..v�>.i /�` • SUBDIVISION NAME
c /�S �/i L L -e_
LOT #
DIRECTIONS TO SITE J�T 6`1 ��
DATE SYSTEM INSTALLED � NAME SYSTEM INSTALLED UNDER C/�"��" I� S� '"�
TYPE FACILITY NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ��� SPECIFY PROBLEM OCCURRING T"' `� �--"'�S
5 '!�-� � � � .4 `"� — � !' e � , ... L► •� c�
DATE REQUESTED v`I INFORMATION TAKEN BY �
This is to artify that the i�forma6on provided is eorreet to the best of my knowledpe, and that I understand 1 em responsible for all charges incurcsd from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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