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968 Liberty Church RdName: w t Directions to property: AUTHORIZATION NO. V,�g",rZAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P O Box 848 PROPERTY ORMATION L'+V ►i;. Mocksville, NC 27028 Subdivision Name: _ Phone #: 336-751-8760 Section: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION 002602 A Road Name: (u �'� Lot: **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 w4en applying ,for Building Pen -nits. (In "compliance witttfArticl�l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. i ENVIRONMENTAL HEALTH SPECIALIJTJ.' DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE I I (�ll�e # 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 wA/rYDESIGN WASTEWATER FLOW (GPD) v NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �L LINEAR FT.�� OTHER == �i t `: j r 1 r / • 1 ! .al I.�S�n.l t b� �[,rJ7c3�JL7 ,�`'l 1 `✓Li1 �►`-(l�._ I�JL l REQUIRED SITE MODIFICATIONS/CONDITIONS: � IMPROVEMENT PERMIT LAYOUT ( -j - c n r: or;T N`�,.j 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 AUTHORIZATION NO. 42W?- 4% OPERATIO ••THE ISSUANCE OF THIS OPERATION PERMIT WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECT GUARANTEE THAT THE SYSTEM WILL FUNC I Wiv aH i iarAt, i vxu, i run tuv z SYSTEM INSTALLED BY: SIhAJ t/U/J DCHD 02102 (Revised) yr i aura. ��� �AVIE COUNTY HEALTH DEPARTMENT -JOEN�f 444- ,ilc - Environmental Health Section PROPERTY INFORMATION P.O. Box 848 - 2 11ir`ections to property: Mocksville, NC 27028 Subdivision Name: 11 i..Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# § SYSTEM CONSTRUCTION AUTHORIZATION`NO: ®2602 A Road Name.' Ur�% p: **NOTEN* 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 l l of:G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPI CIALI§T DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS N# BATHS 1 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No r4 rC f LOT SIZE TYPE WATER SUPPLY .r 1010 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE / SYSTEM SPECIFICATIONS: TANK SIZE - GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH / —� I LINEAR FT. I nTUPP ... /.. 1 f Lrf1l ..� t {• - REQUIRED SITE MODIFICATIONS/CONDITIONS: '~-D IMPROVEMENT PERMIT LAYOUT r ... 4 _.11 . �sF j, l FLw''�i,...T ` l �r NtrJ tt 0 11 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. , I OPERATION PERMIT SYSTEM INSTALLED BY: �T,04 `A" � 1� 01 /1..I FP,0 L CAQQoe r , itp X3U r AUTHORIZATION NO. 2U0 OPERATION PERMIT BY: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE TRAT7Bk S� WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREAT I\ GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY DCHD 07/02 (Revised) a%- � IV- DATE: BOVE BEEN INSTALLED IN COMPLIANCE LL STE SHALL IN NO WAY BE TAKEN AS A OF TIME. i 1!' � `&.:': w LC Log r�° • ar� a4F.�'" �e y s r �, '�e � g a� �;..,� � �� `� r :r� 1M e �. �e�' .�iu '. r � �*2r K '.. �d e�s�i� � "�'� `�iai�' � �, ���.."�,= ���V �',^�" .a i '� "�a5t �,���4�+ „ t� � w, ,. � -f a; °,� �..t�3 �-� w � ��.� � � �:+�`� k c�, s ��5,. 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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ,. APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) PHONE NUMBER hZ SS 13 ADDRESS SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 7 -- TYPE WATER SUPPLY C.eV,.Ltj SPECIFY PROBLEM OCCURRING ,9; L1 -)b DATE REQUESTED 13 Lob INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand 1 am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 key3��l�ivva ij 113