114 Kennen Krest Rd i.Juft e'sAVIE COUNTY HEALTH DEPARTMENT
NameI / Environmental Health Section PROPERTY INFORMATION "
t _ J� . : P.O. Box 848
Directions to property: ��C'f7�r rh" +�`i/" ''�Mocksville;NC 27028 Subdivision Name:'
J
Phone#:336-751=8760
fly Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO. A Road Name: Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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 130k Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
� /5 ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
l E`er ', / i°�•• `('y IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST. DATE ISSUED -
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #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)<! NEW SITE- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE AL. P6WP T )NK GAL. TRENCH WIDTH��rROCK DEPTH LINEAR FT.
OTHER `
REQUIRED SITE MODIFICATIONS/CONDITIONS:
t IMPROVEMENT PERMIT LAYOUT "r
pp ,
F/p jq.
1-ioe MW
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**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 (336)751-8760.
OPERATION PERmraD,165
SYSTEM INSTALLED BY:
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AUTHORIZATION NO.7Q A OPERATION PERMIT BY: ' / / DATE:
.**THE ISSUANCE OF THIS OPERATIONkRMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COM
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 02(02(Revised) }
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) J
NAME � #,/ I e Lo PHONE NUMBER /�" O�0 2 -
ADDRESS SUBDIVISION NAM04A h«J ep-a r
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING M
DATE REQUESTED INFORMATION TAKEN BY
This is to mortify 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.1193