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303 Elmore RdYArTiiitlPe's .. DAVIE COUNTY HEALTH DEPARTMENT �� 3�J/ v Name:'!r"/. ri ,r �; tf Environmental Health Section PROPERTY INFORMATION NJ `) P.O. Box 848 Directions to property:,a..` /i;">'� Mocksville, NC 27028 Subdivision Name: 7/ eP / Phone #: 336-751-8760 o` SeC110n: Lot: AUTHORIZATION FOR WASTEWATER AUTHORIZATION NO: SYSTEM CONSTRUCTION Tax Office PIN:#, Road. Name: 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) ¢> • �� ***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 "e2# 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 (GPDI�� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH v` ROCK DEPTH ✓ LINEAR FT. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT N letlll,f 37-C, VV G. **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. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO..4 OPERATION PERMIT BY:DATE: �,C�, P i **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 02/02 (Revised) M DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) IdcC S,/i 1,P_ , .0c ONE NUMBER ( r t -'_s � 6 BDIVISION NAME LOT # DIRECTIONS T SITE �✓� /k CQ t� 6 �. DATE SYSTEM INSTALLED gS NAME SYSTEM INSTALLED UNDER C1-.tf_'-_^1C e_Ln-�� TYPE FACILITY NUMBER BEDROOMS �- NUMBER PEOPLE SERVED_ TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING_ 424--- as -�-� DATE REQUESTED 3 e 3 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. 1/93 �� ��u P �,.,,, Rd' 3�3 ��1