446 Duard Reavis Rd**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 Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
`,-/7 %r �I t Cr ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
6 ' rf//.� ''y / — (` IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
•dY . r F
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS P # BATHS ' # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) L/V NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE k PUMP TANK GAL. TRENCH WIDTH 36 ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
• I�
3b �k tJ .,
�dG✓t� ' �c4, �
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
� OPERATION PERMIT -
SYSTEM INSTALLED BY: C0 v
f�r
Dpia d� 1( b C) J
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AUTHORIZATION NO. ERATION PERMIT BY: DATEIle:
OPC
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 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.
- -• I O ! �UU�� '
P&iiiittee's
v
i DAVIE
COUNTY HEALTH DEPARTMENT
Name: r��
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Environmental Health Section
PROPERTY INFORMATION
"
/✓
P.O. Box 848
Directions to property::
.
Mocksville, NC 27028
Subdivision Name:
! Phone #: 336-751-8760
'
Section: Lot:
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f
AUTHORIZATION FOR
G' WASTEWATER
(,�t s 1'
n % d /• j r c y
Tax Office PI/)N:# - -
I/
002639 A
SYSTEM CONSTRUCTION
_
t t 3
AUTHORIZATION NO:
Rod Name v'Y 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 Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
`,-/7 %r �I t Cr ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
6 ' rf//.� ''y / — (` IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
•dY . r F
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS P # BATHS ' # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) L/V NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE k PUMP TANK GAL. TRENCH WIDTH 36 ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
• I�
3b �k tJ .,
�dG✓t� ' �c4, �
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
� OPERATION PERMIT -
SYSTEM INSTALLED BY: C0 v
f�r
Dpia d� 1( b C) J
i4ka��
D
AUTHORIZATION NO. ERATION PERMIT BY: DATEIle:
OPC
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 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.
- -• I O ! �UU�� '
y :..�-a4 Y -'ii �wrk',Y. s•p„'.i''�Y :w, r,q,:�y!'6 .♦ .;':+H'rl ,. a{.�'�y :�"/ "'lt'f•t�"'.:.1 ,:.a.�'r 4.. .,�J'bi. wt-z._:.�
f ya '1, .e `.1 -.,...., .4._ ._ vW'•t+o
aPtrtititfitee's �'�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PROPERTY INFORMATION
-
P.O. Box 848
,Directions to property:
Mocksville, NC 27028
Subdivision Name:...--.
Phone #: 336-751-8760
.
Section: Lot:
1
AUTHORIZATION FOR
`� t`1
�,) +
WASTEWATER
Tax Office PIN:# - - -'
it
SYSTEM CONSTRUCTION
0021,39 A
rr (
/Zip• � /`- J
AUTHORIZATION
NO:
Road Name.
w
**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 Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen -nits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS ) # BATHS # OCCUPANTS a GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE I✓
SYSTEM SPECIFICATIONS: TANK SIZE Y GAL. PMP TANK GAL. TRENCH WIDTH 3 6 ROCK DEPTH LINEAR FT. A/)
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: `
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT P
SYSTEM INSTALLED BY: _ 1 (' C'
•-
Ci -I 111,A017
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.
--:" *a I
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME—fri v I ___le-loct-cJ t s PHONE NUMBER 'f Ct'lI�-7
ADDRESS \) D V -V J(�-2 r- tJI, '5 1a SUBDIVISION NAME
LOT # 17 a G r �-5
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED l� 5 NAME SYSTEM INSTALLED UNDER OLLO-y- 5
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED i
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING C, -A- 5 Q'w o�
DATE REQUESTED - r �� INFORMATION TAKEN BYZZ
This is to certify that the information provided is correct to the best of my knowledge. and that I understand 1 am responsible for all charges incurred from this s
SIGNATURE OF OWNER OR AUTHORIZED AGENT 7. 6 9 S5 a--/ ��ct�
Rev. 1/93
Cji *Maps GIS
Page 1 of 6
http://maps.co.davie.nc.us/GoMaps/map/inap.cfm?CFID=17813&CFTOKEN=49736857 4/24/2009