4110 Hwy 158�f4�T,..-S:�e ��'."�.t+1+t[Yty��:�'-'�#'^sal�.^'F.a,,'p:is�. .;�i"_�: fii r t+k'.►:i�a. .a.� .�-.: a%:+._ t..r :.K r-�..x,: r. -::. a ea. -
AUTHORIZATION,NO: 2 O O 5A DAVIE CO-JNTY HEALTH DEPARTMENT
i ,lllpl, pll4v /51LEnvironmental Health Section PROPERTY INFORMATION
`. Permittees 1 �• P.O.Box 848 .L
Na* i1 z Mocksville,NC 27028 Subdivision Name:
� � Phone# 336-751-8760
Section: Lot:
Directions to property: �1 i;�- h r
AUTHORIZATION FOR
/✓c'.I�ri?� d: �� WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTION
Road Name: IS 91 Zip::; 7G,14
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any BuildingPermits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
I-o:>--. IS VALID FOR A PERIOD OF FIVE YEARS. "
ENVIRONMENTAL HEALTH SPECIALIST: DATE ISSUED
pz i 711 = �-
10 4
0 0.5-fl DAVIE COUNTY HEALTH DEPARTMENT
jx4/J4�'; ,q''JMPjWWMENT AND OPERATION PERMITS PROPERTY INFORMATION
Perrintf8e's '"',• ' v ,
`-�artte; Subdivision Name:
�i "r s•,y;a ..�,ra„ : ... ..
t �tions to property: ,� r/{T:i ','`�`� at , : Section: . Lot:
.� IMPROVEMENT
✓.: = ,; �` .r'j' PERMIT - Tax Office PIN:# _
Road Name: S Zip ?�-04**NOTE**T
►'Uhis Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
THORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT.TO REVOCATION IF SITE
—o >-- PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER -
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS ` #BATHS_L#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT . #SEATS INDUSTRIAL WASTE:YesorNo
LOT SIZE TYPE WATER SUPPLY /DESIGN WASTEWATER FLOW(GPD) 6r� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/"j GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEP'T'H�� LINEAR,FT.C?
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYo FILTER* *RISER(S) IF 6+1 BELOW FINISHED GRADE*
Ott
irf Ph
U**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#IN )�dl$hiSO.
(336)751-8761)
OPERATION PERMIT
SYSTEM INSTALLED BY:
r
r
'i
AUTHORIZ
ATION v"`� OPERATION PERMIT BY: DATE: ?/ 0 2—
**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 05/96(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
L APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME :� PHONE NUMBER aO
�0
ADDRESS L1 //� L� S 1-�.--,s l�� SUBDIVISION NAME (�
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED Ln
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
.9'
a\.
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