2622 Liberty Church Rd�eiihito ;,I DAVIE COUNTY HEALTH.DEPARTMENT
Name: -% !+��`'�j� Environmental Health Section PROP RTY. INFORMATION
.� % f P.O. Box 848
Dirmio'ns to property: ��� !� r' f�..l�` Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751=8760
Section: Lot:
AUTHORIZATION FOR
�7�1.I .��:;�� , WASTEWATER Tax Office PIN:#
. SYSTEM CONSTRUCTION
U4//.rillRIZATION NO: 5 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 Pen-nits.
In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
x • r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE# BEDROOMS #BATHS _ # OCCUPANTS 2 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 GAL. PUMP TANK GAL. TRENCH WIDTH s1_!L ROCK DEPTH fi LINEAR FT,0_
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPA TM T FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTA LA ION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTAL B .
AUTHORIZATION NO. OPERATION PERMIT BY: Ap DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE ITEM DESCRIBED ABOVE HAS BEEN INSTALLED W 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.
1 nceD 02/02 atevseQ
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLI9,ATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
ADDRESS SUBDIVISION NAME
(fie( - / LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 2
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED ��� o Z 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.1193