882 Howardtown Circlettee s DAVIE COUNTY HEALTH DEPARTMENT 1,W
e:.: Environmental Health Section PROPERTY INFORMATION
� 4 F.O. Box 848
- Directions to property:li�a1lL'1{!/'1 ` MocKsville, NC 27028 Subdivision Name:
r / Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 2.099A 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
ip''� !• r :y,��L'r f �..y IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL 14EALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE A/ # BEDROOMS # BATHS _ #.00CUPANTS _� GARBAGE DISPOSAL: Yes or'No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLYDESIGN WASTEWATER FLOW (GPD)NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `rte ROCK DEPTH —/2— LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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:
- J
AUTHORIZATION NO, -IV 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 02/02 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
-NAME T7 -PJ )I--> PHONE NUMBER
3V7�
ADDRESS g g %i -d -J X14- .J 69 -r -C L. SUBDIVISION NAME
LOT #
DIRECTIONS TO SIECR ^ ,) 4-
t-7 i r -
DATE SYSTEM INSTALLED �o rS NAME SYSTEM INSTALLED UNDER
Lit ;_pRS sre
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 3
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING /0', /c -'LS- L^.3s �
KenQia? - l )a,_VloL-1L_02aP24- '�-2--1/'5 11- 0 -
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 for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93