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� Permittee:•s �,�-- '"� f , DAVIE COUNTY HEALTH DEPARTMENT /���/���-J
� --',�''r r� ,1 �, PROPERTY II�IFORMATION
�Name: _r�'" � .. � _. C%'/�7 .,� r9 � Environmental Health Sect�on
P.O. Box 848
Direc6ons to property: '� .�� ��Ca i �f� .�C`� - �qocksville.NC 27028 Subdivision Name:
' . .='� '.-- Phone#:336-751-8760
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,:, ,.r, y`�'i`�;'.1�' /:". �-��:�-:"� Section: Lot:
AUTHORIZATION FOR
WASTEWATER
%� .�:: �� t"�f��l�J � O.. �`�� SYSTF.M CONSTRUCTION Tax O fic�PlN:# �
�� I,�aw Z; : ZZd�'
ALJTHORIZATION NO: ���� A Road Name: p
**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 Forni/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits. � •
(ln compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�
�,� �,,/�`,� �y' / ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION
T,`` �"',t,,•Y �f: f�,�,'G.�.'J�J�f^ � r�' ' � IS VALID FOR A PERIOD OF FIVE YEARS.
�RONMENTAL EALTH SP�CIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE.�� #BEllROOMS�#LBATHS � #OCCUPANTS'� GARBAGE DISPOSAL:Yes or No
,
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFf #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY� bESIGN WASTEWATER FLOW(GPD)�J'v NEW SITE REPAIR SITE Y" ��
- /`
7� r ..
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH,`,�� ROCK DEPT �.G LINEAR F'��
.. OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT �
- • ;
� 1
�
�
"*CONTACT A REPRESENTATIVE OF THE DAV1E COUNTY HEA TH EPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DA O INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT _ �
SYSTEM INSTALLED BY:
� /
� /�
� ���
00�3 ''
�
AUTHORIZATION NO�p���OPERATION PERMIT BY: " � DATE: .�!,�-���
-�
'"TI�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
GUARANT'EE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. . '
DCHD 02�02(Revise� . ���� �
. ." �/�v� ���-�
.. . ;:�� � � o
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) CRtt Q,�'�,� �� "��,� Z. w
NAME �'r`4�1L `l�obb%�s - �fn �n�s yYb�Vw��_ pHONE NUMBER K�- �t4�' Z,39�{
_ �
ADDRESS_ _� I 2. SQaur� �c►.t SUBDNISION NAME
rYl�c,K-I v:14. 1�� L?o 2.�'� LOT#
DIRECTIONS TO SITE �olS - �r�o�S�u�t t�- a.rrt../, y h„lii: �" T•�..F� I�a�.�c-l1 �-+ ��Z�'�
�� � �
DATE SYSTEM INSTALLED 3°'�'�'01�'�' NAME SYSTEM INSTALLED UNDER "—`
TYPE FACILITY �''� NUMBER BEDROOMS � NUMBER PEOPLE SERVED -3
TYPE WATER SUPPLY �u t�� SPECIFY PROBLEM OCCURRING Cvq�+�q �d*�•p�:Q/l�s�-
DATE REQUESTED 1"r"�'�� INFORMATION TAKEN B�
T�?,
This is to oHtify that tho information provided is cort�ct to ths best of my knowlsdpe,and that 1 understand I m nsponaible for all chargsa ineurced from this applitation.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Hsv.1�93 , �