1597 Farmington RdPgrmittee'' �• AVIE COUNTY HEALTH DEPARTMENT
'Name: Environmental Health Section
�
?. —";, :` ; `, e ") j/. P.O. Box 848
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PROPERTY INFORMATION
Directions to property: i '�� " N� l �t' 1�1ocksville, NC 27028 Subdivision Name:
r ' Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002637 A
Lot:
Tax Office PIN:# - -
�.'tie/�11/i1(��l1rt
Road Name: .1 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 I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
i„ �� •-, �, ***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 ... GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPPEE� # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE Z�✓ TYPE WATER SUPPLY =� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE,!:!L L PUMP TANK GA(` . TRENCH WIDTH !" ROCK DEPTH �'L� ( LINEAR FT. S
OTHER (f ✓ �' r �/ "� e
REQUIRED SITE MODIFICA
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
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SYSTEM INSTALLED BY:
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AUTHORIZATION NO. OVP3NOPERATION PERMIT BY: DATE:
**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.
DCHD 07/02 (Revised)
Pemiittee's AVIE COUNTY HEALTH DEPARTMENT
'A Skn8 =. � %`�`' Environmental Health Section PROPERTY INFORMATION
'- P.O. Box 848
_ Directions top perty: '' !it' : Mocksville, NC 27028 Subdivision Name:
' f Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002637 A
Tax Office PIN:#
✓1 1 i . : 1F � � s J l 1 y J !r T :•
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
ix IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS r # BATHS '::� # OCCUPANTS `f GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ��l TYPE WATER SUPPLY r1' DESIGN WASTEWATER FLOW (GPD) / fNEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE f� ' `GAL':,, PUMP TANK GAL. TRENCH WIDTH j G ROCK DEPTH �" LINEAR FT. �f
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS4
IMPROVEMENT PERMIT LAYOUT
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: f �• '� / /%i 1_s Io
ell,
IF -tip
('�
AUTHORIZATION NO. 4)l` / OPERATION PERMIT BY: DATE:
**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.
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` DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME ��/ `� ✓ PHONE NUMBER
ADDRESS /� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED kr
TYPE WATER SUPPLY `6 SPECIFY PROBLEM OCCURRING —ale lit %) lGj
DATE REQUESTEINFORMATION TAKEN BY
This is to oertity that the information provided is correct to the best of my knowledge, and hall undo
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
incurred from this application.