118 Sherden Ln . , �-, � � � _ . ,. , : : . : , . : ����^''� .�7��
- �etttit't�" ����,� � J DAVIE COUNTY HEALTH DEPARTMENT
Name: ``���`'"��~`- Environmental Health Section PROPERT,Y�INFORMATION
�L�� ,.T.� P.O. Box 848 � � �-9� c7_�
� _Directions to property: Mocksville,NC 27028 Subdivision Name:
���,,� ��+� f ` �� Lc ,�� ,j,� Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOK
L��� SYSTEM CO STRUCTION Tax Office PIN:# - -
AUTHORIZATION NO: O O Z��Z A Road Name���`�-����''�`�� �Zip: �—�'`-'��
**NOT'E**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 fpr Building Permits.
(ln complia��w�Artic ' 11 ofrC.S.C apter A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/�'"� � -- � -
' / ,�.- ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
L-------"'"` „1- / `� �1 DS IS VALID FOR A PERIOD OF'FIVE YEARS.
ENVIRONlYtE1�T' $�ITH SP�CIALIS DAT ISS�ED
n
RESIDENTIAL SPECIF[CATION:BU[LDING TYPE �I O U_Sf: #BEDROOMS�_#BATHS_�#OCCUPANTS Z- GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILTTY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
1 '^�
LOT SIZE 1��-TYPE WATER SUPPLY �U"? �DESIGN WASTEWATER F[,OW(GPD) � v NEW SITE REPAIR SITE ✓
� r ,� t
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��' ROCK DEPTH 1Z' LINEAR Ff.'Z�
OTHER✓ �1��.I Ql�rl O..� ►.:x�'?�t:r�
REQUIRED SITE MODIFICATIONS/CONDITIONS: ������` � �..rc-"'��T�1�� 1 �'"�� �-�(�t�� (a �``1%�-�
IMPROVEMENT PERMIT LAyOUT
i�l�� �'��i:.�'r•=�' c,'�S i�c--,,,�,..
j ���T MA� L��..�T� � U�-�..`��
� _ �z�,,.::: .�9�;��
►v�
���.���
i��� � �
��� f
.;. -j�;�e.-'"
�, �,�.� -�„
T
��� � q
� r
lC� XS� ,��L• �
:� � ��,,, ��.�J
_. � �,��
�-t I_Sr/nJC� � �
-------_ ,� '
o � � �.5�
- --- .- . _ . .:i..� 'i
' FOR FINAL INSPECTION OF TFIIS SYSTEM PLEASE CALL BET'WEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT ��.�2.ih����
SYSTEM INSTALLED BY:
� �c�r
�$�d�G.t—�"� ��1�...��s�
��
�
�, P� �-S �25� �°�''�
-4-
D��
AUTHORIZATION NO.�_OP ON PERMIT BY: DATE:� '
•tTHE ISSUANCE OF THIS OPERATION IT SHALL INDICATE THAT T E S ESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE '
W1TH ARTICLE 11 OF G.S.CHAP'TER 130A.SECTION.1900"SEWAGE TREATMENT AND DIS�OSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A ,
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ,
DCHD 0?/02(Revised) � � �� '!� i ��
. �-4��. . . . . . . . . . . _ .
lle� Ok ![Jl�//kd � w _ •
T � DAVIE CO NTY ENVIRONMENTAL HEALTH SECTION
' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
� NlkME -�o�1N S�iti�t.✓ PHONE NUMBER 9��� 2 7Zd
ADDRESS !/f' Si1G�c�c�/ �a�✓G � SUBDIVISION NAME
/�o�d'u.��/ II C Z7d Z� LOT#
DIRECTIONS TO SITE�y��- T. Gi� /H �O,-Na✓?U�� /'�C�'i-'►^G on �ti'�LS�G��G�s���
DATE SYSTEM INSTALLED �3d � NAME SYSTEM INSTALLED UNDER �S/1G��
TYPE FACILITY !�!� NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED Z
TYPE WATER SUPPLY - � � SPECIFY PROBLEM OCCURRING G��`Gr �r� �'�-
euc rxa�- �,v.t�i� :jp�a�!'/ ..�"h '_ _l/Q.rao
DATE RE(�UESTED,�T '��'6 J/•�'.. '� INFORMATION KEN
This ia to artity that ths informetion provided is corcect to the best of my kno e ge,an that I ndersta respons ble}or I charpea inQna.ed trom this application.
� �
SIGNATURE OF OWNER OR AUTHORIZED AGE '
Rs+r.1193 ,