142 Eric Rd ! (,.� tr-` ,Jr+;',•' ,.-.4�?e8,•....�..., .,,,,,� .,w, :�:.. .s-Y..�- .s, sz.: �t..r:.:. . - • � ..*.: ..q ti� w ,.. _.
UTHORIZATION NO: 2A DAVIE COUNTY HEALTH DEPARTMENT , � ��` �" '
Environmental Health Section . PROPERTY INFORMATION,
Permitteels J P.O.Box 848
Name: Mocksville,NC 2702$ Subdivision Name:
Phone# 336-751-8760
Directions to property: 511 . �t�� Section:; Lot:'
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION: Tax Office PIN:#
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.l Yof G.S:.Chapter.130A,'Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
;, ***NOTICE***THIS AUTHORIZATION,FOR WASTEWATER CONSTRUCTION
sJ� /S� IS VALID FOR A PERIOD OF FIE-YEARS.
ENVIRONMENTAL HEALTH SPECIALIST, DATE ISSUED
' 2 0 1 2A DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
°Permit ee's
Name: A," li e-j• f1' /`'r Subdivision Name:
r
Directions to property: ' jr Section: Lot:
j j IMPROVEMENT
C "` r% .� f PERMIT Tax Office PIN:# ,D/
Road Name: a _ Zip.
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION 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
j` f rl PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
M f SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE_ #BEDROOMS #BATHS ;Z—#OCCUPANTS J�L_GARBAGE
DISPOSAL:Yes or No ,
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUS I AL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW.(GPD)=' NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHLZ(, / ROCK DEPTH LINEAR FT
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUIRAPPROVED EFFLUENT FILTER* *RISER(S) IF 697 BELOW FINISHED 3RADE*
oil, .91;•
{
**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#ICOM NAPM.'
(336)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY:
/ 1
C
AUTHORIZATION N0. OPERATION PERMIT BY: DATE.
� - �
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
J�
WITH ARTICLE 11 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)
r
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ge- PHONE NUMBER Oma.
ADDRESS SUBDIVISION NAME
e LOT #
A01 >1
DIRECTIONS TO SITE A4 0
r� a
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS <-� NUMBER PEOPLE SERVED
TYPE WATER SUPPLY___/,f & SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that 1 understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93