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AUTHORIZATION NO: 2021 . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee-s'may^- P.O.Box 848
Name: Mocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760
Directions to property: `{,i�s^ .�+��/ Section: Lot: t
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# - -
_ I
Road Name: /!CJ/N af-
**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 Form/Authorization Number should be presented to th&Davie County,Building Inspections
Office when applying foe Building Permits.
(In compliance with Article l 1:of G.S:Chapter 130A.Wastewater.Systems,Section?1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF.FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST MATE ISSUED
► DAVIE COUNTYMEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION'
Permittee's
-Nagle: Subdivision Name:
Directions toproperty: !' '._!`Lry Section: Lot:
r
IMPROVEMENT
PERMIT Tax Office PIN:# - -
' Road Name DIA) �1= `TL`tp G ��
**NOTE**This Improvement Permit DOES NOT authprize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION.FORWASTEWATER SYSTEM CONSTRUCTION.must be obtained from this Department prior to the
coristruction/installation of a system or the issuance of a building permit.
(Inco., liance with Article 11 of G.S:Chapter 130A,Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems);
,r �• ',. ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
}': "` PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST ', DATE ISSUED SYSTEM CONTRACTOR MUST SEE I HIS PERMIT BEFORE'.
INSTALLING THE SYSTEM.
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 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)—` NEW SITE REPAIR SITE i
SYSTEM SPECIFICATIONS: TANKSI ZE GAL. PUMP TANKGAL. TRENCH WIDTH J� ROCK DEPTH /� LINEAR FT �/
OTHER .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUEIIT FILTER} .+ItISEI1(S) IF G" QlrLOV, FIIiISIIED CI3AIJ1±&
vs--
�pIx
**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:
1 �
AUTHORIZATION NO.C OPERATION PERMIT BY: /tel/ DATE: S7
"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.
DCHD 05/96(Revised)
,
Tti r'}
DAVIEiOUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's , E
,.,Nam .e: 3Subdivision Name:
y
Directions to`property: ., `•'J Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name LtJ�A) l_:�� p G of
. **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit. .
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
{' PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE' #BEDROOMS,,---'— #BATHS #OCCUPANTS_ GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATIOk FACILITY TYPE #PEOPLE #PEOPLE/SHIFT r� #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE r TYPE WATER SUPPLY�fi_ DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH J ROCK DEPTH LINEAR FT._:5Vr)
a
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUERT FILTER, *RISER(S) IF 6'• BELOW FIHISIIED GRADE&
Fr
ws
/J
f
"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 r
SYSTEM INSTALLED BY:
1 `
AUTHORIZATION NOA01 OPERATION PERMIT BY: DATE:.,—?/,
"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.
DCHD 05/96(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION
/FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
ADDRESS 0 5 l SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE ( _O/'.ver
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT /
Rev.1193
(�C i V, ��