130 Loop St•Pe�tittcee's," DAVIE COUNTY HEALTII DEPARTMENT„,,,,
Name.: AT -N,% Environmental Health Section PROPERTY INFORMATION
P.O. Box 848: ,
,O
-Dir6ctions to property: , Ci Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
^1 Section: Lot:.
AUTHORIZATION FOR
WASTEWATER' Tax Office PIN:#
�pSYSTEM CONSTRUCTION -
AUTHORIZATION NO: 37 3 ! r� A Road Name:: �0 Lo� 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.
(Incompliance, ithAilicle I of G.S. Chapter 130A; Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
r
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
E IRO M • LTH 'PECIA 1ST DA EIS UED
RESIDENTIAL SPECIFICATION: BUILDING TYPE AOS # BEDROOMS' # BATHS �Z # OCCUPANTS . GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: 'FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPL�CJE * I DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH %—XO ROCK DEPTH + Z LINEAR FT.
OTHER I �, Ljt i2 .4J T7 04
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 INSTALLATION: TELEPHONE # IS (336)751-8760. '
OPERATION PERMIT. pD A_ Mfr t . t`CZ
ncHnovozcRevisea>
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �S
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
SUBDIVISION NAME
8 o Le- e— LOT #
DIRECTIONS TO SITE j kl +t' Co a j �-�-� c
%� S '�c c -,e -N a w Le- f
6-& (1-t- u3{eysd O D -,4:e- s T- C
DATE SYSTEM INSTALLED D + NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY CZ I FI—SPECIFY PROBLEM OCCURRING. t �f—
DATE REQUESTED 2 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. 1/93