1468 Fork Bixby Rds 7 ; DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
•ctions eb property: � F' ;1 r % I / /Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
el Section: Lot:
AUTHORIZATION FOR
AUTHORIZATION NO: $
A
WASTEWATER
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 Perrnits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 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 I�? # BATHS ,% # OCCUPANTS __4? GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY &�Z DESIGN WASTEWATER FLOW (GPD) ? �/� NEWSITE REPAIR SITE s(
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCKDEPTH �� I EAR FT. r=
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"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. j2 ee-OPERATION PERMIT BY: DATE: 44zltl�
"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)
t� b�
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
a
NAME PHONE NUMBER IV-
ADDRESS lg6d' SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE . IZ+ h, filj.- j W- aAe j. 1yti+. Le. ^..4.F%
DATE SYSTEM INSTALLED_/9G0 G/ NAME SYSTEM INSTALLED UNDER_ /'./'. e• Z"'Wej
TYPE FACILITY UP- NUMBER BEDROOMS -3 NUMBER PEOPLE SERVED 3
0
TYPE WATER SUPPLY Gr/Gll SPECIFY PROBLEM OCCURRING T/4 Jlrw civ G �
sre'm do
DATE REQUESTED 5_'P-03 INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I under and I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT)( C ,
Rev. 1193