561 Jack Booe Rds
Peftli tee's, 3 DAVIE COUNTY HEALTH DEPARTMENT
Nama: `� rlEnvironmental Health Section PROPERTY INFORMATION
„ --P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
s
Phone #: 336-751-8760
.-- Section: Lot:
+" AUTHORIZATION FOR
!`rr� tWASTEWATER
/SYSTEM CONSTRUCTION Tax Office PIN:# - -
AUTHORIZATION NO: 002621 Road Na Tock Rwe
**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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
Xe ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
i �•'; ' << �. %. , %L. ' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE le # BEDROOMS _ # BATHS _3 # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT L/ # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) e NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK L. TRENCIW�TJ ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
T
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. n-� "' OPERATION PERMIT BY: / DATE.
**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.
DCHnozrozcRevIxa, �oc{' g899000aS _[-NU-a�'9
+ Peinuttee�s ,(� DAVIE COUNTY HEALTH DEPARTMENT
'kNamo-: ' "� C' ` �%��-1 Environmental Health Section ` PROPERTY INFORMATION
P.O. Box 848
( 2bireations to property: / Mocksville, NC 27028 Subdivision Name:
k
f` Phone #: 336-751-8760
Section: Lot:
•, ' ,,:. - ;' AUTHORIZATION FOR
Y, ' WASTEWATER Tax OPIN:#
SOffice YSTEM CONSTRUCTION -
AUTHORIZATION NO: 002621 A Road Nar;;! C k 1?66 e 7zi,
**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 Forrn/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)
r
ENVIRONMENTAL HEALTH SPECIALIST
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
k, IS VALID FOR A PERIOD OF FIVE YEARS.
DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS _ R # 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) -�" %f`-` NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH W16TH ROCK DEPTH LINEAR FT.
�•.:: ,.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: F' $
IMPROVEMENT PERMIT LAYOUT
1917 �.
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
t/
i „r
a
AUTHORIZATION NO. OPERATION PERMIT BY: ,' f DATE:
"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.
Dciinoaio2cRev,see> h(7c %1V `10 9gOONY 1_NU. 5a�9
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME ArS PHONE NUMBER f
ADDRESSol�� s�j ��'L SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING C__ C
i
DATE REQUESTEINFORMATION TAKEN BYE
This is to certify that the information provided is correct to the best of my knowiedg d that I understand I
SIGNATURE OF OWNER OR AUTHORIZED AGENT r/ � d
Rev. 1193
charges incurred from this application.
AKO
W)Kg11-1rcfJ1* DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
InOCkbVJ % IV( 7-76*PPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
n - ))A) -
NAM
DIRECTIONS
PHONE NUMBER
BDIVISION NAME
LOT #
DATE SYSTEM INSTALLED 0 E NAME SYSTEM INSTALLED UNDER
TYPE FACILITY & ffNUMBER BEDROOMSNUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED O
RMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and thj0;vndeVtand !,AA rp9ponsible forffl charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
.Tivv,we-A 519(o