1505 Jericho Church Rd .. o _YC` � .. . c _ _.-. . - ' _t'. � . �, -.. .f err,•
PYrmitteel- ; DAVIE COUNTY HEALTH DEPARTMENT .
Name:" cii�e� �si/ Environmental Health Section PROPERTY INFORMATION
` n P.O. Box 848
Directions to property: fir:i• tip c f,• ES Mocksville,NC 27028 Subdivision Name:
fir (i € 741st, r r, r �' C Phone#:336-751-8760 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002945 A Road Name: 1,. cl• Zip: Z
**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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
P 't'{'' �'t�y IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS 3 #BATHS / #OCCUPANTS GARBAGE DISPOSAL:Yes ordVa-
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE Z 4p nor"YPE WATER SUPPLY r, DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITEy�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK_ GAL. TRENCH WIDTH -3L ROCK DEPTH 111-4- LINEAR FT.
OTHER /[��rr�C.-•-� ��-
y
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
f
%j 3
1
>L:n
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 PERMITtT
-1a ti/< a�(C eil ^1�3'YO 2 INSTALLED BY: - 5a n
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AUTHORIZATION NO. OPERATION PERMIT BY:
DATE-
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT IFIESZ Tl th � �- '1 lAS BEEN I IN COMPLIANCE
WITH ARTICLE I 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.
DCHD 01!02(Revised) • �2�2N a O rl
P nfiStt . , DAVIE COUNTY HEALTH DEPARTMENT ,,,i
Environmental Health Section PROPERTY INFORMATION
_� ' P.O.Box 848 J
Directions to property: j` �' 'i'r,f `" Mocksville,NC 27028 Subdivision Name:
Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002945 A 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 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
j ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS 3 #BATHS / #OCCUPANTS -3 GARBAGE DISPOSAL:Yes or.NcY
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or"No
f
LOT SIZE-L)o rt/"TYPE WATER SUPPLY /'�j DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
' � r
` SYSTEM SPECIFICATIONS: TANK SIZE �'I-P GAL. PUMP TANK e✓/�� GAL. TRENCH WIDTH x4 ROCK DEPTH �f/�
� LINEAR FTF -�
OTHER �-
- 1
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT Z G%rl,
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r
1
12
kh,�
it
---------------------------
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 `'u 1 -
/\ Q SYSTEM INSTALLED BY: 1-56 n
i 4
AUTHORIZATION NO. oy OPERATION PERMIT BY: - F
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE"SYST E HAS BEEN INSTAL D 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.
Dail)=2(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
✓,
APPLIC
ATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME J��N l� 0 PHONE NUMBER
ADDRESS 156,!� oefichb N SUBDIVISION NAME
I l LOT #
DIRECTIONS TO ;hr
SDG[ 11 JN(1i6
DlV 4o AX&6 J"ryAM
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY Q NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �Wefi
SPECIFY PROBLEM OCCURRING j Alk-
DATE REQUESTED 3O INFORMATION TAKEN BY t6
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am esponsi or all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT <o^t�^t��\�
Rev.1/93
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