113 Drum Ln-•.--�-.-�:...i,�=..._: ._..'., _ __ ,` _.-. __ _. ._ __ __ �... ..- - �� � , . . .. _ ' .
.✓ ♦ . .. ., i -s. �� .�... : . .. � ..
. -' . �"- r •,..-.� � � . . . . . . . � - . ' i r' O � � '�...;�� .,'...�'. '_'..�_ _ + :.t,_..._ � �� r,y�.
Au�rHoxtzATiorv rro: �' AVIE COUNTY HEALTH DEPARTMENT �'�I �` 6 Z'
. �,�s�� �
' ; _. _ __ . -.� Environmental Health Section PROPERTY INFORMATION
Permittee' � ., P.O. Box 848
Name:_��,��/�� 0�/i'� Mocksville, NC 27028 Subdivision Name:
,� � Phone # 336-751-8760
Directions to property: x /`Gi �'yl' /�/�"� Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTF,M CONSTRUCTION - -
Road Name: Zip:
**NOTE** This Autharization for Wastewater System Constn�ction MUST BE ISSCJED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Forni/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 11 of �'i.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f ; �
� � ,-� �''/ � �yl� � ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r'� ,��Cl� �� yJ �,�1`��'-> ,l"/,Q`--.�� IS VALm FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
. __
� � , . . * _ - . . . . . _ , : . ..�
_ � � :� �i �!}`�DAVIE COUNTY HEALTH DEPARTMENT'1 � `� � /�/6 �'"`
"- �' �`'- -���+ TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
� �,�-,-; - �
PCrniittee's � r'� -
Name: ( � t .� � !�.�. �} �% �,',/ K-
f'. } r ���
Directions to property: �. E t�:r•�'+ !'. !� e.
Il1IPROVEMENT
PERMIT
Subdivision Name:
Section: Lot:
Tax Office PIN:#
Road Name: Zip:
**NOTE** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
ALTTHORIZAT'ION FOR WASTEWATER SYSTEM CONSTRUCfION must be obtained from this Department prior to the
construction/installation of a system or ihe issuance of a building pernut.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
-:.,„.,, " '� " ***NOTICE*** THIS PERNIIT LS SUBJECT TO REVOCATION IF SITE
`, ;" � +-� i' ,.: -�, �`--�,,✓' %'`K,� j� 7 PLANS OR THE INTENDED USE.CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE ,�� # BEDROOMS _,� # BATHS �# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �r !� NEW SITE REPAIR SITE,�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �(6 � r ROCK DEPTH ��jLINEAR FI'. '�• r��
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENTPERMITLAYOUT�RRFR�V�D EFFLUC��T FIL�iER�=' �'RI�Cfdi5) IF
y�
, �����i
�
I ��
�' j r �"��� \
��
c{ �'�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTIO�1�(.��j�'�S�YSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # I�S�7��6�a�76�7��
I OPERATION PERMIT
SYSTEM INSTALLED BY: ___��ol6,G�F° ti—�, N�L�d�%lY/�
��l�--�o
� �%�' �.�� � �
�,
+-
AUTHORIZATION NO.� OPERATION PERMTI' BY: �� DATE: � l/ �
**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 OS/96 (Revised)
NAM
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
`��
ADDRESS �� 2-C.�,�.� ,� SUBDIVISION NAME
�.
I%�� c L� S` �( I�� 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 certi(y 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. t/93