266 Gladstone Rdti
�II
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
` P.O. Box 848
PROPERTF R N/o3
property:---( Ld.—, f Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
AUTHORIZATION FOR
r- C. WASTEWATER
� ' SYSTEM CONSTRUCTION
1 1 C
AUTHORIZATION NO. �A
ons to
Section:
Lot:
Tax Office PIN:#
n �L
Road Name:t�'`fg~~ Ltp:
**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)
- /I.! / , I
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENViRONMENTA0HEI3LTH SPECIALIST D) TE ISSUED
I KK
RESIDENTIAL SPECIFICATION: BUILDING TYPE hl,L# BEDROOMS ,.,'� # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE �/ # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE YPE WATER SUPPLY 6l DESIGN WASTEWATER FLOW (GPD _ NEW SITE REPAIR SITE '"
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1! LINEAR Fr,FC — r
___7'
OTHER V ! / Sl k✓i rJ V tl c��—`C���✓� S .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
G -v t:Q C
IMPROVEMENT PERMIT LAYOUT
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126i/L. N
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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
SYSTEM INSTALLED BY:
p
/60
Sr ,
AUTHORIZATION NO. yr OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S E DESCRIBED AB E H S BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATME T A D DISPOSAL SYSTE ", 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 �J / l �l� � C3 PHONE NUMBER
ADDRESS CG/ SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
c7 N /Z r JA V
DATE SYSTEM INSTALLED �w-ef-9y� NAME SYSTEM INSTALLED UNDER
TYPE FACILITY ? NUMBER BEDROOMS NUMBER PEOPLE SERVEDS
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRINGc/�—�+1-,.re•�!
DATE REQUESTED 22 Z>3 INFORMATION TAKEN BY /O
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/ktSC� j a,hh_�)
Rev. 1/93