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1283 Main Church Rd � .- �,.:..�' . .. . � . � _r .. �_. .�..T T,�.�._ .__:., t :S .� ..,',� ��J' `4, .r �,.:.t � ':,.��r �;, .. � -:..• t:":�.. "' . � Per�ittee's � � ' DAV E COUNTY HEALTH DEPARTMENT~ ��� '' '�'���j` `�'�� , \ ti -...-y Name:` �-� ������ �E'1��t-i ��_�: ��� )�- Environmental Health Section PR RTY INFO�RMAOT/I� •--��-�-�'•- , . . ,, r P.O. Box 848 ��i��' v '_ , �. n. Directions to property,: � .�'� � 1 `"' ►,J/J, , Mocksville,NC 27028 ` Subdivision Name: i.,:� l,.1�:.,►*� ��-'� '}� �t��•,,� , Phone#:336 751=8760 " �. Section: Lot:' � � �� Cti � ti . AUTHORIZATION FOR � . ;t�.:��_�> f ��,. } !i WASTEWATER :Tax Office PIN:# f �=� T—�� SYSTF,M CONSTRUCTION , � ' � ` � . , ���1 _ . AUTHORI7ATION NO: A'' - �' Road Name: C�� � ^ i � J�p:�� . **NOTE**This Authorization for Wastewater System Conswction MUST BE'ISSUED by the Davie County:Environmental Health Section prior to issuance of any Building Pernuts.This Forn�/Authorization Number should be presented ro the Davie County Building lnspections Office when applying for Building Permits. ' , (ln compl�ance with A�tic e 11 of G.S. ha ;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �'; �' '. ***�IOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION /-�t f3'� ': IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENT H A IS A'`i'E ISS D '. _ . ' ; _ .. #BEllROOMS ` #g> , . , ., ... • •, , , , RESIDENTIAL SPECIFICATION:BUILDING TYPE`�"I� � ATHS 2- #OCCUPANTS 2- GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFISHIFf #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE '� �r Q�T PE WATER SUPPLY�'DESIGN WASTEWATER FLO�'�'(GPDj I f NEW SITE REPAIR SITE � 1 , . � � ,. , � � �SYSTEM SPECIFICATIONS! TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH �Z LINEAR Ff. t �� �' , n� . OTHER > I ��_STIG�I.��� �C.� � REQUIRED SITE MODIFICATIONS/CONDITIONS:�L�E� I/'� l:-X I��T 1�(� U��'s�� %� r?'vi� , e IMPROVEMENT PERM[T LAYOUT ���r '�(L���% • ,..;: s , �'�� , f;. ,�. ,� ;, : , ��:� ���, � � �`��,,� - 7 � ,,.. 7p� .:. , . � . ; ' ; ; � � � ��``�-��S ` � � �V�`L�,� �"���j � � � , � , -_._... � *'CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION �IS SYST�EM BETWEEN 8:30-9:30 A.M.OR 1:00-7:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-876Q"�"�—�— OPERATION PERMIT � ,.., . ; SYSTEM INSTALLED BY: �� k/ . " 1 �,r� �d � I' ` � _ ",:; ,, . � . _ , _. ,-...:;: , -: � �: ' � �('� AUTHORIZATION N . � PERATION PERMIT BY: DATE:� /J ��1�� . •'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HASBEEN INSTALLED IN COMPLIANCE ,< WTTH 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. • nCxn o2oz�e�;�e� '�� ,e _ �n",� � ���� . . ,: , a: � , � �2� iss "O' / �o� 1 ' � . 'S7 ;�> -../ �� ; �,� .�`i� ��N�� ; ����� �;�:�u w � ��� � � , � �-(9.00A}�,� �� �� � `,�: �� ������ ����.�'� ;� . ` t�006� - �� �„ I� 9074 ��' �4i� .,,�, . 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'�.. �.ti �� � ,.: ��" \ti; .��. �:4 \ . � � � .. . . .. 1 ss � ,, r. ,,. .� _ � �t � � �� ' �: , ��� �.. ,� � _ �� � � � r � t 1 02 C : 1 ; � , �, �' 0177 .. �,. { y.. 339 �. �� ua�e 1 500 . ' -^ ,(., . . Iro� ` �y �,, � �' ► � la .;��.' ` , . DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION . APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME �N le° � �-��.�e 5 PHONE NUMBER ��� ��a v ADDRESS ���3 ,/�L�/� ��u-�"L�� ' SUBDIVISION NAME . � � G�S� t �I2., LOT # ' DIREC ONS TO SITE ���C4-�"" �� `S"�`' �r�c l�. i�t�-- �. J � DATE SYSTEM INSTALLED 35y �s � NAME SYSTEM INSTALLED UNDER ? � a , � TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY C� �� SP CIFY PR BLEM OCCURRING �-�� '7� � � g . . , � : �� �--�� . � (�� �D DATE REQUESTED �y7' • INFORMATION TAKEN BY �T This is to o�rtily that the information providsd is eon�ct to th�best of my knowlsdp�,and that I und�ratand�sm r�sponsible}or all eharpes incurted from this application. � ' SIGNATURE OF OWNER OR AUTHORIZED AGENT� _ /ll„�-�-�-� '`•� Fw.1�93 • \� _. C�-,�,. .�Z—e�- �-' a �B'