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AUTffORIZATION NO;-Q 7 5 9 DAVIE COUNTY HEALTH DEPARTMENT ��0.0
"Environmental Health Section PROPERTY INFORMATION
Per�sitceP.O.Box 848'
`"Name;'-- 7Mocksville,NC 27028 Subdivision Name: ~
Phone#:704-634-8760
Directions to property:zw--�%• Section: Lot:
AUTHORIZATION FOR
2 ll WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
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Road Name: „sN >:� c� *.
P.,
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**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)
_QQ
***NOTICE**,*,THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� ) IIS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST;'.: :,DATE ISSUED
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.. t DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Perrll��es W; — c ,
Narne: �� �.' Subdivision Name: t
Directions toroe ,.J j:,;. ` .. ,
p p rty: Section: Lot:
' IMPROVEMENT
PERMIT
Tax Office PIN:#
Road Name :`; „
Zip: ¢�
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE Q#BEDROOMS 3 ,-#BATHS #OCCUPANTS 4 GARBAGE DISPOSAL.Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE--�, #PEOPLE/SHIFr #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE CSr-mlk TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH M LINEAR FT. ay
OTHER J
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
t.�
EE E7
R,
**CONTACT A REPRESENTATIVE OF THE DAVIF.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 INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT (1
SYSTEM INSTALLED BY:
ti
bW , � yams
N ll
_ 1
�d
AUTHORIZATION NO.V OPERATION PERMIT ( ` �
0 BY: ��? DATE:
**THE ISSUANCE OF THIS'OPERATIONPERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 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 05/96(Revised)
i
rQ
DAVIE COUNTY HEALTH DEPARTMENT
-'" =` IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION '.
" Periile 's
,
Name:' >` �' Subdivision Name: �.
Directions to property: ' - Section: Lot:
" IMPROVEMENT
,1 PERMIT Tax Office PIN:#
j Road Name Zip:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE�N• "t,#BEDROOMS "D ,—#BATHS #OCCUPANTS Ll GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE�b #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE� TYPE WATER SUPPLY G DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �' ROCK DEPTH t LINEAR FT.
s .
OTHER a
REQUIRED SITE MODIFICATIONS/CONDITIONS:e
IMPROVEMENT PERMIT LAYOUT
lj
1 .
160 A
**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 INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
a a '
AUTHORIZATION NU. OPERATION PERMIT BY: w l DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT'THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 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 05/96(Revised)
r
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME /' 1. PHONE NUMBER
ADDRESS �d��� (� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
-7171
c .
DAqE SYSTEM INSTALLED MW _NAME SYSTEM INSTALLED UNDER
TYPE FACILITY V NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRINGT'y -�
r
t 0- -P,
lL S•
DATE REQUESTED 7 �� `9 7 INFORMATION TAKEN BY `GAJ
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_ C_" -
Rev.1/93
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