157 Fawn Ln**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-HI�ALTH SPECIALIST bXTO ISSOrb
RESIDENTIAL SPECIFICATION: BUILDING TYPE 11� # BEDROOMS - # BATHS:-^•* # OCCUPANTS —Z� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT —# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE f n TYPE WATER SUPPLY �\��—I—�-- DESIGN WASTEWATER FLOW (GPD) /` NEW SITE REPAIR SITE
-7 I�
SYSTEM SPECIFICATIONS: TANK SIZ . GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1Z_ LINEAR FT.14 )
P^
nTT4P V 9 � �'_: J I k51 1 L: `..� i) � � �/' ��i /`.a . 11 ``��L� 1�-- �) i'a.iii� � iJ .� • i�.I f V
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT>!, YOUT (CIL x 1 e ra L? IV
f�
Q iV
**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 r �
SYSTEM INSTALLED BY:
'A7_3
woroa �
T w � C 5IY6
AUTHORIZATION NOF— ��`� OPE ATION PERMIT BY: DATE: J
**THE ISSUANCE OF THIS OPERATION PE IT SHALL INIFIA THAT THE SYSTEM ESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S. CHAPTER 130A, S TMENT AN DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEMWILLFUNCTION SATISFACTORILY FOR AN PERIOD OF TIME.
DCHD 02102 (Revised) - dM � / 0 %i%/VK �� O�
OA- kujod,,�.--�
Pprrdttee's .- r w
DAVIE COUNTY
HEALTH DEPARTMENT
_
Name: p�f+ 1-3 (�
1i 4 l ;\ti,; Environmental
Health Section
PROP5RTY INFORMATION
'
'-1
P.O. Box 848G�c3'
DtreGtions to property: , �._=
(
Mocksville, NC 27028
Subdivision Name:
%L '. �.! - :1;° 't_ ``?
'� t : h t..
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER
Tax Office PIN:#�
SYSTEM CONSTRUCTION
bZtp:
AUTHORIZATION NO:
A
Road Name:,'" ^�
**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-HI�ALTH SPECIALIST bXTO ISSOrb
RESIDENTIAL SPECIFICATION: BUILDING TYPE 11� # BEDROOMS - # BATHS:-^•* # OCCUPANTS —Z� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT —# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE f n TYPE WATER SUPPLY �\��—I—�-- DESIGN WASTEWATER FLOW (GPD) /` NEW SITE REPAIR SITE
-7 I�
SYSTEM SPECIFICATIONS: TANK SIZ . GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1Z_ LINEAR FT.14 )
P^
nTT4P V 9 � �'_: J I k51 1 L: `..� i) � � �/' ��i /`.a . 11 ``��L� 1�-- �) i'a.iii� � iJ .� • i�.I f V
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT>!, YOUT (CIL x 1 e ra L? IV
f�
Q iV
**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 r �
SYSTEM INSTALLED BY:
'A7_3
woroa �
T w � C 5IY6
AUTHORIZATION NOF— ��`� OPE ATION PERMIT BY: DATE: J
**THE ISSUANCE OF THIS OPERATION PE IT SHALL INIFIA THAT THE SYSTEM ESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S. CHAPTER 130A, S TMENT AN DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEMWILLFUNCTION SATISFACTORILY FOR AN PERIOD OF TIME.
DCHD 02102 (Revised) - dM � / 0 %i%/VK �� O�
\\ d Milk M-
>:
\\.��
< 2 «:»:
� »v«§:�
. y
i
0 o
J
l �
I
c
0
i9
u
I LU A .v, r1Z:r 1 i7,%L ' 3 - /
do��,.�, DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
-fJAME
e -b r -/--k-4 S K, - PHONE NUMBER 33 6-76 7 7/s a
� j �—/
ADDRESS �V� �-� � � SUBDIVISION NAME
2 —7 LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER �"``s •r �/ /e,,, /,�'�
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 3 �-
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING ° 1 d
1• \\
DATE REQUESTED �-� o 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 r q 15
/ � i 39