128 Naaman LnPemiittee's, j DAVIE COUNTY HEALTH DEPARTMENT
Name!��, ;/i %+' Environmental Health Section
P.O. Box 848
PROPERTY INFORMATION
Directions to property: f_.�r i/-� ,I t s•`� ', Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
AUTHORIZATION NO: a l6 A
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
Section:
Tax Office PIN:# -
Lot:
Road Name: 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.
(In 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 ✓ f �'� +:, rrr :'r y"l r) ' / f: ,� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSU16
RESIDENTIAL SPECIFICATION: BUILDING TYPE / # BEDROOMS � # BATHS # OCCUPANTS -ew'V GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)y ! + t!� NEW SITE REPAIR SITE _
/ ! f`
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHS ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
/:2 I
C
Y�
Y
**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:
AUTHORIZATION NO.� OPERATION PERMIT BY: DATE: 1 0
**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 SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 07102 (Revised)`�— /
Pernuttee's, =' s ��~a DAVIE COUNTY HEALTH DEPARTMENT ` 6n
; 1. r'. Environmental Health Section ROPERTY INFORMATION
P.O. Box 848
"Directions to property:
` ' 4"! ;�� ; ,2l ,, .
; ;.r'. Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
WASTEWATER
Tax Office PIN:#_
SYSTEM CONSTRUCTION
AUTHORIZATION NO:
A
Road Name:
_ Lot: '
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.
(In compliance with Article I 1 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 SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE %�� #BEDROOMS #BATHS
-,7)- # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE . # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)r NEW SITE REPAIR SITE D
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ,�_ ROCK DEPTH LINEAR FT.f
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
ti
*"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:
AUTHORIZATION NO.,g,�6L OPERATION PERMIT BY: /� DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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.
DCHD 02/02 (Revised)
Li
�DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) G�
NAME No-,tt ren S� PHONE NUMBER � d S �F 3
ADDRESS / O2� Jk) SUBDIVISION NAME
j/1 D C `� S ✓./ / -� c- 2-Fa �- d LOT #
DIRECTIONS TO SITE !-�' i- t�,��• �� %�
7D'ATE SYSTEM INSTALLED 5 NAME SYSTEM INSTALLED UNDER ),j '
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED 2"
TYPE WATER SUPPLY__y PROBLEM OCCURRINGc� ('� C "e c
DATE REQUESTED /3 /a INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193