372 Junction Rd 1?e.;mittee's ; DAME COUNTY HEALTH"DEPARTMENT
r" ' PROPERTY INFORMATION
Name: 'art .. r t Environmental Health Section
6x.848 4;
Directions to property Yom: Ile 1166 to rlL
r a r - ENioc � 1 , C 27028 Subdivision Name:
Phone#:336-751-8760
J k )` Section: Lot: '
' AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# _
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 2271 A Road Name: dA) Zip:
f
**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)
�" t ly�,/',.* , ✓ r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAZHEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW(GPD)�d d NEW SITE REPAIR SITE t
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK, GAL. TRENCH WIDTH ROCK DEPTH: /LINEAR FT«
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**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: /
S
AUTHORIZATION NO._1�Z lOPERATION,PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
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.
ncno 02/02(Revised) o � .21
�s
Penittee's DAVIE COUNTY HEALTH DEPARTMENT
N�ine:;r `�✓ .{ ,r ` `,, Environmental Health Section PROPERTY INFORMATION
Y^{ P Q.Box 848
Directions to,property:'. E.
locfcsVille,NC 27028 Subdivision Name: a ic% /F '141
`F S
Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
.'
WASTEWATER Tax Office PIN:# -
�. SYSTEM CONSTRUCTION
AUTHORIZATION NO: ,f {' A Road Na VUf�G�l OAU 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)
t .
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED j
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS W% #BATHS #OCCUPANT$ GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY C DESIGN WASTEWATER FLOW(GPD) ��`�� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK----GAL. TRENCH WIDTH % ROCK DEPTR LINEAR F r. a
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT h
"CONTACT AREPRESENTATIVE 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 IVAI
SYSTEM INSTALLED BY: /
10
1 n�
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: / v
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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.
ncEto 02102(Revised) C -44
9 75
• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) t
NAME PHONE NUMBER
ADDRESS 7 �— J ti�i�i a�. - SUBDIVISION NAME
U�
LOT #
DIRECTIONS TO SITE l �-�-�-r c• ••� 3�7' �w� • Es Y' _
DATE SYSTEM INSTALLED ' �lS
NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
r
TYPE WATER SUPPLY Wo'll SPECIFY PROBLEM OCCURRING *_B Qeo—�-"Ajj
DATE REQUESTED 1 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
L rte-.L.