510 Gun Club RdPermitteP's DAVIE COUNTY HEALTH DEPARTMENT
-Nate: `' ' (! f t� :f` Environmental Health Section OPERTY INFORMATION
P.O. Box 848 22_ 3 —
r Directions to property: ,4 f
%' Mocksville NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#,
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 1 A
Road Name:
Lot:
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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t
' C' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE✓/ # BEDROOMS 4,L4, # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE�y # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yews or
No
LOTSIZE TYPE WATER SUPPLY ` DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH o ROCK DEPTH �, LINEAR FT. /t�o
REQUIRED SITE MODIFICATIONS/CONDITIONS:
I OPERATION PERMIT
;W)
SYSTEM INSTALLED BY:T�' _I �{�`v!_t-y)/ _ aC,
AUTHORIZATION NO. o?la7 OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 02102 (Revised)
r
NAME�-
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION V15-4— Re I +y
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) '5' q 1-OC4,'-7 cl-4 Z(
W R ^�'�� �� T) PHONE NUMBER _s
17 /0.?
ADDRESS �! �u-- GLcc8 �. SUBDIVISION NAME
DIRECTIONS TO
'7
LOT #
% u._.
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER Lj
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING ��r—,fie t c-5
D
2 � (L
DATE REQUESTED b 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. 1/93
y /z 3 '- 3 y _--s— � �� &,,,—— --�-t,
-
�x� ~
DAVIE COUNTY HEALTH DEPARTMENT
. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
^NOTE:Issued inCompliance With Article ofG.G.(�hupter13Ou
Sanitary Sewage . mm ����^ Permit Number
_ U�� � �> ���
Name
Date u�� " , �^v
Location
Subdivision Nome Lot No. Seo or Block No
Lot Size House Mobile Home -_____-_ Business --- Speculation
No. Bedrooms No. Baths No. in Fami|y__��____
Garbage Disposal YES [] NO []' Specifications for System:
Auto Dish Washer YES NO []
Auto Wash Machine YES NO []
Typo Water Supply
*This permit permitVoid ifsewage system described below io not installed within 5years from date ofissue.
This permit )osubject to revocation if site plans or the intended use change.
/mpmvemants permit by
°Contaota representative of the Davie County Health Department for fina| inspection of this ayobam between 8:30-
9:30 A.M.
:3O'S:3O &K4. or 1:00'1:30 P.M. on day of completion. Telephone Number: 704'G34-5885.
Final Installation Diagram: System Installed by
~ � ~
.� Yi/
~�
�^
� .
Certificate ofCompletion Date
'The signing of this certificate ohmU indicate that the system described above has been installed in compliance with
the standards sot forth in the above vaQu|a1ion, but shall in NOway betaken as oguuxanteee that the system will function
satisfactorily for any given period oftime.