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_ ,_h�„HGQIZATION NO: � � � ��AVIE COUNTY HEALTH DEPARTMENT �-
Environmental Health Section PROPERTY INFORMATION
Permittee's �.. ,� P.O. Box 848
Name: �/°S�� ��t%i%D� � Mocksville, NC 27028 SubdivisionName:
`� Phone # 336-751-8760 '
Directions to propert�( :�'.� 1 ii�.l ��� _ Section: Lot:
J � U HORIZATION FOR
�����,, (" `� /�?y�� /"�,� � fy �� �- �v���WASTEWATER Tax Office PIN:# - - _
� � SYSTF,M CONSTRUCTION
Road Name: 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 Form/Authorization Number should be pre�ented ro the Davie County Building Inspections
Office when applying for Building Permits.
(ln com�liance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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ENTAL'HEALTH S �C
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DATE ISSUED
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
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. �j � '� �'��"DAVIE COUNTY HEALTH DEPARTMENT
, ' = - TMPROVEMENT AND OPERATION PERMITS
Permittee's � � ' ,
Name: - =�_"� :�-!`�c`' y� '�.Gt.�t� �.
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�" Directions to property: �' - f�` ' j,' _ 1'; �; �
_ �,f Il1IPROVEMENT
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� , ;,_ %� J � .�: PERMTI'
. �����'-� `;� � `E { f;.�l f !�- .� : t��, � ���`� .
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PROPERTY INFORMATION�"�
Subdivision Name:
Section ` Lo[: ;
Tax Office PIN:#
Road Name: Zip: _
**NOTE** This Impravement Pernut DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system. An
AiTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Departrnent prior to the
construction/inst� "�ation of a system or the issuance of a building pernut.
(In compliance with Articte �1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
:' �' �', i.r� ��' , � * r� ***NOTICE*** THLS PERMIT IS SUBJECT TO REVOCATION IF SITE
x-�``��;� ,�'�,;�'� .�''n�,��, ,',;"r' , i`r PLANS OR TI-IE IlVTENDED USE CHANGE. YOUR WASTEWATER
:::. ,,', �,%'
;NViRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
, INSTALLING Ti� SYSTEM.
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RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEDROOMS _� # BATHS �L # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFTCATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE �'""��
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SYSTEM SPECIFICATIONS: TANK SIZFf n0� GAL. PUMP TANK GAL. TRENCH WIDTH ���' ROCK DEPTH � LINEAR FT��
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT � ��pROVCA F�FLU'���
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IF 6" %:lCl:d �= It:;it�? �'=l] G�i�B��
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 930 A.M. OR I:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (?Urt�633:8�X60iX
t33�)7�1—@76�
I OPERATION PERMTf
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. �/ /�/ �OPERATION PERMIT BY: Cik��_ ' DATE: v�� �
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
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 OS/96 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME �� SS� �IJ i d c� � PHONE NUMBER
ADDRESS 1% 7 � lI v v t-t�► G I �O ��- t SUBDIVISION NAME
� c— I�S V ' LOT #
DIRECTIONS TO SITE
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 in}ormation provided is correct to the best of my k�owledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
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