3709 Hwy 801N}/ Permittees / DAVIE COUNTY HEALTH DEPARTMENT
Name: r ��.(/�. L 4/) ��.-1Environmental Health Section PROPERTY INFORMATION
r 'P.O. Box 848;
Directions to property: [� l 00\� Mocksville, NC 27028 Subdivision Name:
goldPhone #: 336-751-8760
• ^" `� �' ' Section: Lot:
AUTHORIZATION, FOR
WASTEWATER .
��• 0q2� hid%� Tax Office PIN:# -
f SYSTEM CONSTRUCTION
AUTHO IZATION NO: 2164 1 A Road Name: i�� 1 Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countyl5nvironmental 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.
(1n compliance with Article l I of G.S. Chapter 130A,,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
!^- ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
7S VALID FOR A PERIOD OF FIVE YEARS.
NVIRONMEN1`A- L HEALTH SPECIALIST. DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TY P # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yews or No
LOT SIZE TYPE WATER SUPPLY `-�'�t— DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE !�' GA �PPUMP TANK GAL. TRENCH WIDTH. ROCK DEPTH c� LINEAR FT.�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
rM
q10k 3)
o
/00
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINALINSPECTION 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.
**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.
YJ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION='
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME �V�-�aA La- e-J'� PHONE NUMBER_���'
ADDRESS ° -k a _70 P4 L) 6 -AC -C SUBDIVISION NAME
i o LOT #
DIRECTIONS TO SITE a?e--'5 ('P4qbSg&On II
a') /<j 3114
DATE SYSTEM INSTALLED `` NAME SYSTEM INSTALLED UNDER
-���-
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING c-1 ia2
4
DATE REQUESTED_ I ' I S ° v INFORMATION TAKEN BY l�-
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