1574 Jericho Church RdPennittee's - DAVIE COUNTY HEALTH DEPARTMENT
'Name: Environmental Health Section
10 . - I -T P.O. Box 848
SCI S
PROPERTY INFORMATION
Directions to property: r •Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
�:` i r';';�' .''i'•l' Section:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION —
AUTHORIZATION NO. 2 ' Z A
Road Name:
Lot:
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)
! , ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
} s'r r c` IS VALID FOR A PERIOD OF FIVE YEARS.
EN VIRONMENTAL'HEA°LTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS _� # OCCUPANTS -,P 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) G NEW SITE REPAIR SITE �J
c
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �5,f ' ,ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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 INSTALLATIONITELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY
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W 6�«
AUTHORIZATION NO. OPERATION PERMIT B DATE: ID ZJ 3
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE M DESCRIBED�TEMS
S BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSALSBUTSHALL IN NOWAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME ��no �-� e-� 2 PHONE NUMBER l-7
-,5�
ADDRESS %4�- _7%1 1 -A-r1 1-k, CG' • kakSUBDIVISION NAME
yy�_ cLe-S;,II -e
LOT #
DIRECTIONS TO SITE L a I (• y '�" -+ `'`-'�"' l� s?' `� " s ^•.� �,L"`sL`s�" sJ
,3�•-s r ro &r /V iat S r�-c_ (� "�,J iv -S a ti 6 a,c ti}-a.n t ria J,
DATE SYSTEM INSTALLEDNAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 3
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED w 13T 3 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