264 Four Corners Rde nitte�e's j y DAVIE COUNTY HEALTH DEPARTMENT
Name. t -22)r LL' Environmental Health Section PROPERTY NFORMATION
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Ave � i ; j P.O. Box 848 �� 3-- �7— Q --P
Directions to property. '-+ ,s arj t""': lrr! te'I Mocksville, NC 27028 Subdivision Name:
r Phone #: 336-751-8760
A" Section:
AUTHORIZATION FOR
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Lot:
Office PIN:# - -
SYSTEM CONSTRUCTION Tax w
AUTHORIZATION NO: '� ` A Road Name: D--4' C (BIW Slip: -2'7 o�
**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 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
j fir' �, ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
Jy.: "' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS =I--_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY A/,F/DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ` —"
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH C ROCK DEPTH /-�LINEAR FT.�3��
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUTz'J (4/_1 �y
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"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
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r
AUTHORIZATION NO. EOPERATION PERMIT BY: _
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE
WITH ARTICLE 1 I OF G.S. CHAPTER 130A, SECTION .1900 "SEWAC
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOR
DCHD 02102 (Revised)
SYSTEM INSTALLED BY:
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DATE: L
�T THE SYSTEM DPI E H S BEEN INSTALLED IN COMPLIANCE
ENT AND DISPOSAL SITIE.
E UT SHALL IN NO WAY BETAKEN AS A
FOR ANY GIVEN PERIOD OF
i
NAME Q_�tce_c �-4_'.,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER—77r- 74 - -3�'�"?
ADDRESS �—Co `f -0 -I1 )Zk --SUBDIVISION NAME
Y)/\- 0 ckS 1) 1 1 /e- LOT #
DIRECTIONS TO
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DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED , )— 3— k� S INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I uncle
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93