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771 Markland Rd ,::, ,. w::: „ .x ., . . , . . .:.� �..,.. ., . .. .; _ . �; „ ,. , ._, . - : .: . . . . . . , . . . . "� . . . . .. . _ ... . .,� -,. t� . -Permiu,;e's `� ' . 71 DAVIE COUNTY HEALTH DEPARTMENT �� 3 �Z�`�J� �. ' .�1ame: - ��+�'1���''���n O i' Environmental Health Section PROPERTY II�TFORMATION , � f P.O.Box 848 , J, Directions to propertyi ���/ �Ir;1z'�i''•1�1��/`'_`�/ Mocksville,NC 27028 Subdivision Name: ; � � � . Phone#:336-751-8760 �s'� �.�?'/;�rl � �`F , Section: Lot: AUTHORIZATION FOR - WASTEWATER Tax Office PIN:# SYSTF.M CONSTRUCTION - - ,,. AUTHORIZATION NO: ���.�� p ' Road Name: �' e�.� �iip:�7 D�L . **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie CountyEnvironmental Health Section prior to issuance of any Building Permits,This Form/Authorizatian Number should be presented to the Davie County Building Inspections, ` Office when apPlying focBuilding Pennits. _ : ' (ln compliance with Artide U_of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ` "�/ �;r �J � r;'" ��,. ; ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,,.�c..,`'�,t f�F;���.�`�`,�'�-�' G � �' J,-,�_.._.. " IS VALID FOR A PERIOD OF FIVE YEARS. t � NVIRONMENTAL HEALTH SPECIALIST DA E4� : : RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS �� #BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No � COMMERCIAL SPECIFICATION: FACILITY TYPE' #PEOPLE #PEOPLFJSHIFT #SEATS' INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY� DESIGN WASTEWATER FI.OW(GPD)S:2J�"L[L NEW SITE REPAIR SITE� . SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL.4rTRENCH WIDTH� ROCK DEPTH� LINEAR FT`� .. . . . , . . .j.r ,!��,� .,, � . . - . . ,. , . . � . . . . - '! .. r,����4:1 ....i�<. . , . . . OTHER . •, , � 0 REQUIRED SITE MODIFICATIONS/CONDITIONS: ' IMPROVEMENT PERMIT LAYOUT . ` ... (� � /" **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 / ' / SYSTEM INSTALLED BY: �Y ,. ' /d : • � ' AUTHORIZATION NO��Z��OPERATION PERMIT BY: �' DATE: �` ��/ "'"THE ISSUANCE OF THIS OPERATION PERMITSHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE W1TH ARTICLE 11 OF G.S.CHAP'fER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ncxn mrm���s�a, 3. �� � C� � �� `3 , Y � _ _1 ,� - _ .."' -,:._,� .;� - �� - ,„�.,- .. . . ,,., rt� � . ' � r µ ,� � ..i . ., _ _, . . �.,, � . .. . �'�-�. �_pgm��S �"��� �;: f DAVIE COUNTY HEAJT.�TH DEPARTMENT` � -� f ,��,t �' C i ; ['i�':y�{''" `id''u�� 1 l' - . . . . .. . . �" t` " ,�/j10 �"' Environmental Health Section ,� PROPERTY INFORMATION f.r ,. ,;. -•, . , . ' ,...1,r r�� w .� ^ d� P.O.Box 8�38 DirecdoTts�o property: � r'` � �`"�� r�•r'�^� � ' ' 'Mocksville,NC.27028 Subdivision Name: Phone#:336-751=8760 - `:- F. . •. a:°" _ Section: Lot: t � AUTHORIZATION FOR �' . � � WASTEWATER Tax Office PIN:# SYSTF,M CONSTRUCTION - - ALJTHORIZATION NO: �,�.��� A Road Name: � �C.K�u i� '�-�Zip;„��QC j. **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Counry 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. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � ! ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION r� � �� �� ,.� ,• .:, ..��<''�. "i.''� �_„_f IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DA`fE ISSUED �:,,� ' , : � �, . ' .RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS � #BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No ; � - COMMERCIAL SPECIFICATION:!;FACILTI'Y TYPE #PEOPLE #PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No . � LOT SIZE TYPE WATER SUPPLY �G, DESIGN WASTEWATER FLOW(GPD)�;'`� '-c� NEW SITE REPAIR SITE� f,: . , y r �, � } SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL •TRENCH WIDTH .�� ROCK DEPTH j� LINEAR� . OTHER _ REQUIRED SITE MODIFICATIONS/CONDITIONS: ' , IMPROVEMENT PERMIT LAYOUT.• � ; ' ' � , . , , °j' ; i . ...�«--�- : . . . . � '. , , .. : _ ��' � . . . . � .. . . . ' � . .,�. � �:� � � .�� . � :. ' : � -: ,. .. '`��; . .. � � � � . . . . _ � � .� . .. � �. . - . ' . ' . . . . � • .. . . . . . . . . � �;. � �" . � , ..�' . . ' . .. . � . . � . . ..��. . . . .,'. . - ..�.�. . .. . **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[NSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: � � ` �` � /D � ' .Y � ��, _ E . . . . . � . . . . . . . . � . . . � � ... . . _ . . .. . [ , � . . . . . ' ., .� . . . . . � . � : . � � � � . .. . . //� '� AUTHORIZATION NCk���l�N(� OPERATION PERMIT BY: � DATE: �� � *'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE , WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SY�TEMS",BUT SHALL IN NO WAY•BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. . DCHD 07J02(Revise� : , C/t../��'�� �, . , / � � ,, ;� � � , t ' � � �j� � �� : - �. . .... . . , � ,, . � ._ , ,r.�.. _._�_., , -.� , ,� �-- - . , .._ . . � r �' �' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �"'� J APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) � NAME C_���w �! /�a 2 PHONE NUMBER � �� �- G•�� � ADDRESS � 7f � �1 ��-�'—�� �• SUBDIVISION NAME � � 1J'a-�..-L.� 2�Q�f , � LOT# e � DIRECTIONS TO SITE�Y'�� �� � ��C �� (`t L— � � • / ��.,/-cz � � Z � �� � � ' � DATE SYSTEM INSTALL D �'�� NAME SYSTEM INSTALLED UNDER ��'`�y `r! �N`� : TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED ,� TYPE W�1TER SUPPLY �`-�l/ SPECIFY PROBLEM OCCURRING C ���-�-- �, D l� s�• - � '�-a-�- -� � �1 � � DATE REQUESTED � a o INFORMATION TAKEN BY (�-� � �' E �Thit is to aAify that tha i�formation provided is eorrect to the best o(my knowledge,and that I und�ratand I am r�sponaible tor all charyes incurrsd from this application. fJ r � SIGNATURE OF OWNER OR AUTHORIZED AGENT �'-� ,t Rw.,ry3 . 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