290 Riverdale Rd ,.. _�, z _, . . ,
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AUTHORIZATION NO: ` �� ,� DA .
` � ' ' 'Environmental Health Sect�on
t VIE COUNTY HEALTH DEPARTMENT PROPERTy iNFORMATtorr ;
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Permittee's P.O.:Box 848
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Name:` ' ./� ' '�f Mocksville,NC 27028 `Subdivisibn Name:
1 ` - $.. Phone# 336-751-8760 '
. Directions to property: �,� i� � ��. ' ' Section: ' Lof:
� AUTHORIZATION FOR �
.�����/���/�� '�,/�,� '' WASTEWATER Tax Office PIN:# - -
� SYSTF.M CONSTRUCTION
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Road Name: � Zip: '
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- **NOT'E**This Authorizationfor Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
- to issuance of,any Building=Permits.This Form/Authorizatiqn Number should be presented to the Davie County Building'Inspections;
Office when applying for Building Permits, ' � : ,
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(ln compliance with,Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) - �
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' '�**NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
-, ��'�` C'���.:: y,,+',, �f'� � . `i'� G;'�. IS VALm FOR A PERIOD OF FIVE YEARS. '
ENVIRONMENTAL HEALT SPECIALIST;; DATE ISSUED ,
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' � ���� � � � _. ��.# � � ��,�DAVIE COUNTY HEALTH DEPARTMENT . - ' $�a r'- z�'`� ` Z
' . � » `' � � ' TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
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j P�rmit[ee's
• � . Name• �f' ��F-,�r� !r'"/ s Subdivision Name.
. Directions to property: �� '1 � �, .�`x�� ,rr`�� Section: Lot: r
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� : Il1'ItPROVEMENT .
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.� ;';.;', ,.;*"✓,;�'jlr �L� �` PERNIIT Tax Office PIN:# - -
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**NOTE**This Improvement Pernut DOES NOT authorize the consWction or installation of a septic tank system or any wastewater system.An
ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/fnstallation of a system or the issuance of a building pemut: ` '
(In compliance witti Article 11 of G.S.Chapter 130A,Wastewater Systems,Section#1900 Sewage Treatment and Disposal Systems)
'� . �
,<- -,'� 't,;:s**NOTICE**�THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE
, ...-= i >r: r'; :'" . •�''` f . .="'1_':; . ,r'` , . �' `4�PLANS OR THE IlVTENDED USE CHANGE.YOUR WASTEWATER , ,
� ENVIRONMENTAL HEALT'H SPECIALIST DATE ISSU�D {'. `SYSTEM CONTRACTOR MUST SEE 1�IIS PERMIT BEFORE.
• i �, ` INSTALLING THE SYSTEM.
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RESIDENTIAL SPECIFICAITON:BUILDING TYPE�� #BEDROOMS�#BATHS_�#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD) NEW SITE ' ' REPAIR SITE
Y
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH —�� ��ROCK DEPTH��LINEAR FT.���
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OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENTPERMTTLAYOUT�EAPPROVED EFFLl1�1VT FILTER�• � ISER�5} IF 6" BELOt! FINISH._FD GRADE� :
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•*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPE �S{YSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS � �-��
tC��6)�5�[•=g76�
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OPERATION PERMIT �
SYSTEM INSTALLED BY: �
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AUTHORIZATION N0. � v OP�RATION PERMIT BY: DATE: / C- � �
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**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF.G.S.CHAP'fER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BLTT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII,L FUNGTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96(Revised).. _ .
' ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION d�
� • � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �
NAME 'e�l /� �- �L' �l7ti c`� "� PHONE NUMBER (`b .
` ADDRESS � �� l�� t/�1 G�`� /�
SUBDIVISION NAME �
-�,a C� a �, /�J �—
LOT # �
DIRECTIONS TO SITE �
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DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �''
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DATE REC�UESTED � INFORMATION TAKEN BY �e�/�--
This is to csrtify that the information provided ia eorceet to the best of my knowledge,and that I understand I am rosponaible tor eli charpes incurred(rom this epplication.
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SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93
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