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1582 Main Church Rd f .. , r:_ , '__::_' ;::: .: :' , . . . ... / /'" . - . � -. -- . --. . � _.. ,.. .r-..,',, .. . �....:� e4;r . ...., .. �<. ' ,:. : '. + :F. .. . . . . . . .`"'y'. .�v t �-- �F..�,t F� 1 fG,.. . _. �_'PerniSttee's• � ! • DAVIE COUNTY HEALTH.DEPARTMENT ' � �"�y!� '`�Name:��`"'7���.`t�.t�N�C�� Environmental Health Section PROPERTY I FORMATION - ��� P.O. Box 848 , � � � , Direcu�ons to property: R�E'.(W"� � --.�J=�='�: : Mocksville;NC 27028 Subdivision Name: ��� � i���" : .��!�*�,,] �! �...�. Phone#:336-751-8760 _ , Section: Lot: ' ` AUTHORIZATION.FOR ' ' ; WASTEWATER Tax Office P1N:# ' SYSTEM CONSTRUCTION - - AUTHORIZATION NO: ��� J ' , ��,,,_,r� f'"'��1 i t� �t���sJ`�'u Z� A : Road Name: ip. **NOT'E**This Authorization for Wastewater System Construction MUST BE'ISSUED by the Davie Counry' Environmental Health Section prior to issuance of any Build'ing Perrnits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Perrnits. . (ln compl�ance witt��Article 1.1 of .SrEtia er 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) _ f� � � f ': ,./'� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '; ,,...-„,,�,,... . � �., . � ,.., I.,.- f"�, � : IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRO ENT L��LTH SPECIALIST . -DATE(SSUED . • . �Y _ :; . , RESIDENTIAL SPECIFICATION:BUILDING TYPE M f'� #BEUROOMS � #BATHS � #OCCUPANTS I GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFf #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY ��� DESIGN WASTEWATER FLOW(GPD)��v NEW SITE REPAIR SITE_�.� y,,,,� �" 9 ,t , ,SYSTEM SPECIFICATIONS: TANK SIZE�W v GAL. PUMP TANK GAL. TRENCH WIDTH�� ROCK DEPTH 'v LINEAR FT. � OTHER � �-' 'ST4:n�✓1 l b.J ��j� REQUIRED SITE MODIFICATIONS/CONDITIONS: ��� n�'�' (./� �Nr�v� � �` . (�t or� ' ��• �'`�� IMPROVEMENT PERMIT LAYOUT `` : .e , . .� . . : . . . . . . .� ` ��.. �� r•;.��2. . � � � � �. � . � . . � � . . '. : ��� .�'� . . �,�:,��� � � � � �� ��� .;. .F-�o��' �`*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 �S�-I�='�LW�.�.� �U�J� • SYSTEM INSTALLED BY: ' ��' ',��`'�'�t 2 '��y� �� : ►---�'_'�1f � 1�`� � � iT �� I � {v� ,�ou..:` � : : _; �fw,�.�'j' _ �j�'�`�� � -�� : AUTHORIZATION NO. �4�Q OPERATION PERMIT BY: DATE: � 9- *�THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS DES D ABOVE EN 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. nci�n ovaz t�����a> ' ov /d . ��� ��7 � �� � � _ • _ �.� '� � �Z� ( � °�»� � . �� � �-�_�� � � � ��� ��,; � .�_ �,� � �. �, ar � � �,�, m�.�� � o ,�,,g�, '�� � n �ca: ,�'`� a '� y'�q � �. �`°` �� x� 1, « m� n A�'� � � ��a�a° � i�k. r v��� rv� .! `��, � a " � P k � � �e � $ � $. . �l �� 'ap � � �} `��" a( i� B@.M'^ � � ' �.� �k �x *`� � v ��{ � N ���`� -r a �.7�"� ''�s.� �� .� r � � � � �. � r�° � q �� a� p . ; '� � � �''� " ._�� �t_i a a '�'��. ��� . � '�3.36A)�� �"� ��- ��� � �� �; � � •` .� �� ,.�p ��t �q � a� t� tl '�9°� . ° � m' �� �y� r�� � ,n ° R'k� ' .. � "fr � " � . . � � � ° .�`aY! r ��� w � � � � �� � �� � ��� ����� •" � ��� � !� ��. , � � ,. 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" '�� ,mi.i.. ^� 4' -••'.� gi��`� ` ..� :<. �� . � � �- . � � : ,; > r '� , o. �' � e � , r. .x , � ea� Po� 0 4 � �..� k,�1 :.r� � _ � .ky 1 . � � ,a ..W.: . ` — � T �» 8. ��� `��.� ' � p � .li ' � 1' 'm`A ..�' � �p � � �— � > "v ° n i j � �� .w` ° ; �-' e �. . . ��' � � ���R `� � �� ' ' T ���$ �_ � � . � �� _, � . �_ .. _ _. `-� ; __s--- �iiRF��� _r_ . _ _ �.� G-�- c.��-- W-���� � �� �.: C��e � '�' � DAVIE COUNTY ENVIRONMENTAL HEALTH SEC ION C, � ' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) +vlAl� _ / �O PHONE NUMBER ` ��� ���" ADDR S � � �I ���1/�/ Gf� SUBDIVISION NAME s� 1"� Q-'�D�S �Sg Z ti�S i a l`.�} LOT # � ` DIRECTIONS TO SITE � � �O �N'�`- � o s� "�� � � •G L��- � N / �' d /` 't� �-- � S i O�� (�G,�t¢..,_ �-G��✓�-- -� DATE SYSTEM INSTALLED -�� NAME SYSTEM INSTA ED UNDER. �• �' TYPE FACILITY ` NUMBER BEDROOMS�' ?� ° NUMBER PEOPLE SERVED I � TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �'�-�-��y'-�r � � � DATE REQUESTED � O' "INFORMATION TAKEN BY '� . � This is!o wrtify that th�info►mation provided ie eortect to the best of my knowledps,and that I understand I am nsponsib�e}or all charyes incurcsd from thia application. � '. SIGNATURE OF OWNER OR AUTHORIZED AGENT �.,roa