728 Fork Bixby Rd4� ' Permittee' ,,r, JT r,, x_ ,r, DAVIE COUNTY HEALTH DEPARTMENT
Name: ! " r ..,; Environmental Health Section PROPERTY INFORMATION
,),,.' / P.O. Box 848
Directions to property:,, ✓' L� i - !' f'' Mocksville NC 27028 Subdivision Name:
AUTHORIZATION NO
/,,/ Section:
Phone #: 336-751-8760
"/, .�' G/ Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
0025'9 A
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
% 16, 6/ i' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS `2_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT�� / # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY f DESIGN WASTEWATER FLOW (GPpy3j ` NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH—= ROCK DEPTH JNEAR FT.
OTHER
-dJ_ Z -A z
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT j
w fIt .
i r
9 ,
t i _
I�
11 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. I
OPERATION PERMIT
I SYSTEM INSTALLED BY:
Cj4x�e!-,c
AUTHORIZATION NO. " OPERATION PERMIT BY: DATE:
"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 AI
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 0=2 (Revised)
0
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME t PHONE NUMBER
ADDRESS � �-« �r�� y SUBDIVISION NAME
DIRECTIONS TO S
�6 P-- K— C
LOT #
DATE SYSTEM INSTALLED Sa �S NAME SYSTEM INSTALLED UNDER—
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY C-�V SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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 !pr all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT �- rxfAoL�t� �, 1D��-��
Rev. 1/93