226 Edwards RdPermitieesrJ • r" �'DAVIE COUNTY HEALTH DEPARTMENT
Name: ii1�t 1 ' Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property:�U✓T I>*'`� �"' Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 2 ` . A Road Name: 1�G' G 11Y._ip:..
**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 applyin for Building Permits.
(In eompliancew tI► Art�j I I ,C,,S a ter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON tCt TALkiFAi I`H SPECIALI T; DATEItSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE tL_ # PEOPLE # PEOPLE/SHIFT # SEATS - INDUSTRIAL WASTE: Yes or I
LOT SIZE TYPE WATER SUPPLY _{a(�� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE / UDOGAL`* PUMP TANK GAL. TRENCH WIDTH IP' ROCK DEPTH J r LINEAR FT. %C�7
OTHER��
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
SYSTEM INSTALLED BY:
�L�
O 4 ST
(b - 14-04
AUTHORIZATION NO. 140,24 OP ATION PERMIT B DATE: �� n
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO S 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 02102 (Revised
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) 2
NAME �'`� � PHONE NUMBER 'IM 2'79 U
BRESSL-LI ��
A RESS �'I"�41L.� SUBDIVISION NAME
nl!I LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED �S NAME SYSTEM INSTALLED UNDER � M
r.
TYPE FACILITY NUMBER BEDROOMS S..- NUMBER PEOPLE SERVED
TYPE WATER SUPPLY' SPECIFY PROBLEM OCCURRING �
DATE REQUESTED SIL -7I/ INFORMATION TAKEN BY
This is to certify 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. 1193