316 Stagecoach Rd . ..::
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r Pe�r,niccee's , ,, �,D,AVYE COUNTY HEALTH DEPARTMENT
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!'f/-�(/r"��''',�°S'' P.O. Box 848
Directions to property: Mocksville,NC 27028 Subdivision Name:
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� y � -�� , �,- �� � ',,� Phone#; 336-751-8760
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\�,f ���f 7'� �_ ��i� �`.•-c, �`C Section: Lot:
� � AUTHORIZATION FOK
�'���-�_-� ��j,,i �%/��— � � WASTEWA'�F.R Tax Office PIN:# - -
� SYSTF.M CONSTRUCTION 7
AUTHORIZATION NO: Q�2��� A Road id'a��:�7���L7,((��? 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.7'his Forni/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Perrnits.
(ln.compliance with A�icj�l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal System�)
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�����.�f ,�' ��,� / ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
` ��f I� 1'G�",��',�`'�,'j r� -. t`� �� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE�_ #BEllROOMS�#BATHS_,�#OCCUPANTS I GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY�ES1GN WASTEWATER FLOW(GPD)��NEW SITE REPAIR SITE ��
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�v Cf ROCK DEPTH f�t LINEAR FI'.C��
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: %
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AUTHORIZATION NO.��OPERATION PERMIT BY: DA'I'E: S
"`�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.
DCtID 02/02(Revised) �.^C/`-�� � `1-�d,—� �� ���G��C
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' . DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
' � � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �
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NAME�cSs�e. NP�►�c�/t,:Gl� PHONE NUMBER `�'0��'•�`�2�
ADDRESS 3 I` S`�'a('.e..Coae� � SUBDIVISION NAME
Yh'vK•� . LOT # -
DIRECTIONS TO SITE G � w�T•l�F� DAv�t {k.a� � � Qa*,�-CC�.�.�.., S�e-� - �fs �-��o ,
S��e.��.1.� - 4,uw k. e..� e-.-Q
DATE SYSTEM INSTALLED ��Nr�a�,o NAME SYSTEM INSTALLED UNDER ��� �t.�+�
TYPE FACILITY �v�i� NUMBER BEDROOMS NUMBER.PEOPLE SERVED �
TYPE WATER SUPPLY W��1 SPECIFY PROBLEM OCCURRING.QT�,T,eb.�o� n�- h�+ L�`�--
DATE REQUESTED g'3�" ��� INFORMATION TAKEN BY�
Thii is to o�rtify that the iniormation provided is correet to the best of my knowledye,and that I underetand I am nsponaible lor all chargss incuned hom thia application.
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SIGNATURE OF OWNER OR AUTHORIZED AGENT
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