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Permittee's/� DAVIE COUNTY HEALTH DEPARTMENT
Name: l V.CI*.I r-..1 Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Lgi� "lt" 8.t A Mocksville, NC 27028 Subdivision Name:
r Phone #: 336-751-8760
�►, rte,%L Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# _
SYSTEM CONSTRUCTION„
AUTHORIZATION NO: 2064 A Road Name: �v� _� 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRdN' N EALTH SP CCALIST DAT 1S UED
RESIDENTIAL SPECIFICATION: BUILDING TYPEf'� # BEDROOMS #BATHS % # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE
I # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE V 4(VTYPE WATER SUPPLY WW—'DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH I Z LINEAR FT. 1
OTHER1 )�IL�.t71�Tjt�^J laJC
REQUIRED SITE MODIFICATIONS/CONDITIONS: _ -� A Lt b/A C vA700R
.rerrmttee's . ;, . 1 , DAVIE COUNTY HEALTH DEPARTMENT
` f Environmental Health Section PROPERTY INFORMATION
Name. 3..•t ,. s �t� `r
P.O. Box 848
`
Directions to prrperty Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
�.. `x L i.= 'I Section:
Lot:
AUTHORIZATION FOR
WASTEWATER TaxOfficePIN:#
t ' SY,STEM CONSTRUCTION - -
AUTHORIZATION N0: 4 A Road Name: 1 Zip:t
**NOTE** This Authorization for Wastewater Sys'te'm 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
hf; ' IS VALID FOR A -PERIOD OF FIVE YEARS.
ENVIR Nc tNYAILHEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE -1G . # BEDROOMS # BATHS r # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZEf /-S if-" PE WATER SUPPLY LQ— DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH,_ -.-1 ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: i t • vA ]0L)_ y
IMPROVEMENT PERMIT L
L-
C� 1ti 1 ��
'l
(�
L)
0
NAME_____
ADD
DIRECTIONS TO S
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)'
PHONE NUMBER
/s
BDIVISION NAME Mp
LOT #
DATE SYSTEM INSTALLED -5 NAME SYSTEM INSTALLED UNDER C7y L_ L ,e ,j dLff
TYPE FACILITY NUMBER BEDROOMS : -- NUMBER PEOPLE SERVED
TYPE WATER SUPPLY l/� � SPECIFY PROBLEM OCCURRING _c'7-e_
a r -
r I IVc�
DATE REQUESTED (?2— INFORMATION TAKEN BY Q: f —
This is to certify that the information provided is correct to the best of my knowledge, ajoat I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT.
Rev. 1/93