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214 Odell Myers RdPermittee's f- DAVIE COUNTY HEALTH DEPARTMENT , 'Name:��� 1 fw ," +✓ •.. fa - Environmental Health Section P.O. Box 848 PROP RTY INFORMATION Directions to property: /zf' ocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 1; �;��{ � Section: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#_ SYSTEM CONSTRUCTION AUTHORIZATION NO. A 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 Forrrt/Authorization Number should be presented to the Davie County Building Inspections Office when applying,forBuildin Pe its. s - (In compliance with At cle`t] of G.S. Chap[er 1301, Wastewater Systems Section'. 1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION fYl) Y ) w r ', ✓� L IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED a� RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS «••' # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE • 7 (TYPE WATER SUPPLY PIV" % DESIGN WASTEWATER FLOW (GPD) C �� NEW SITE REPAIR SITE L 42 SYSTEM SPECIFICATIONS: TANK SIZFy,GAL. PUMP TANK GAL. TRENCH WIDTH �. ROCK DEPTH LINEAR FT. D{1 REQUIRED SITE MODIFICATIONS/CONDITIONS: _ IMPROVEMENT PERMIT LAYOUT Ir **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: ,�j -1 AUTHORIZATION NO. 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. 40 7� 7� DCHD 02/02 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Envlmnmenta/ Health Section P.O. Boa 848/210 Hospital Street rl Mockaville, NC 27028 V (336)751-8760 ***IiP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS THE REQUIRED 002 INFORMATION IS PROVIDED. Refer to the INFOMSTION BULLETIN fo in tions. `( 1. Name to be Billed rl� h i /� �c SP Contact Parson y ' io j n TA; H4CTH Mailing Address Home Phone 'kyo — -g City/stat•/ZIP / ` Business Phone 117% 2. Name on permit/ATC if Different than Above Nailing Address City/sta ip 3. Application For: ❑ Site Evaluation 0 Imp va�ePeimit/ATC IY// Both 4. system to Service: House ❑ Mobile Home ❑ Business ❑ Industry 0 Other 5. If Residence: # People r9— # Bedrooms .:2— # Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/industry/Other: Specify type # people # Sinks # Commodes # showers # Urinals # water Coolers IF FOODSERVICE: # Seats Estimated stater Usage (gallons per day) 7. Type of water supply: 0 County/City (/dell ❑ Community 9. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: v�?, ! cc J31�10 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax once PIN: # ,St/ - a3 19? &1 � -Fxq 4 l e :� �m Property Address: Road Name C� 1-�yP�_' ,,-,(L 1%5 City/ZipAeloAlyeeAle, If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, If the site plans or intended use change, or if the information submitted In this application is falsified or changed. I, also, understand that I am responsible for all charges Incumd from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Depar n nt to enter upon above described property located in Davie County and owned by '%� • D to conduct /all testing procedures as necessary to determine the site suitability. 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