1201 Wagner Rd �
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. +.'%;�r�r >. f�"���� Environmental Health Section PROPERTY INFORMATION
.- � ,#� P.O. Box 848
Dir�tions to property:%` '�w� ' '.� �l`�'f ` Mocksville,NC 27028 Subdivision Name:
� ✓� % � r�',.% �=�,r` Phone#: 336-751-8760
�?.•,"`�If�� � �,°�;..:�' -r`�.'r� ��� ' �''f„ Section: Lot:
y M, AUTHORIZATION FOR
�r'};_,,;.� �,-'� '�J WASTEWATER Tax Office PIN:# - -
SYSTF,M CONSTRUCTION
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AUTHORIZATION NO: � ' �'�s�� � A Road Name:_ !J� xhyt Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Pemtits."This Form/Authorization Number should be presented to the Davie Counry Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 17 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
%�''' � _,�': + ? �w' �" '"'�� �«�'***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
,,� ^�,J�..��i w,��',��{��'�.��fi� �.�+'1�y''�,. �I�. ��. �,o�.,'�s � � � IS VALID FOR A PERIOD OF FIVE YEARS. �
ENVIRONMENTAL HEALTH SPECIAL(ST DATE ISSUED
f �
RESIDENTIAL SPECIFICATION:BUILDING TYPE �'�'" #BEllROOMS�#BATHS /' #OCCUPANTS �'� GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
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LOT SIZE TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW(GPD)�'-�^� j`%� NEW SITE REPAIR SITE �"`
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SYSTEM SPECIFICATTONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �r.�' ROCK DEPTH� LINEAR Ff.C^=r��`�
OTHER . , ",;`,: ;i:r:
. . .: �
REQUIRED SITE MODIFICATIONS/CONDITIONS: • , "�" ' ' '
IMPROVEMENT PERMIT LAYOUT ,
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**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 I STALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT �
SYSTEM INSTA D BY: L��'- O9k-
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N N . L� �OPERATION PERMIT BY: " C�U
AUTHORIZATIO O S`� 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 01/02(Revised) �i��l_- �� �/
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� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION p
�„ f '' LIC TION FOR IMPROVEMENT PERMIT(REPAIR) ,y,� �
NAME Q � � l i S PHONE NUMBER
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ADDRESS � SUBDIVISION NAME
�'/"/Y� " i G� �c--..- LOT #
DIRECTIONS TO SITE O ✓ 7� '� � S' i/ . � ��
1�� ���� f�91 �
DATE SYSTEM INSTALLED � � NAME SYSTEM INSTALLED UNDER /S��
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
,
TYPE WATER SUPPLY � � SPECIFY PROBLEM OCCURRING �G"�GL�
DATE REQUESTED - �� INFORMATION TAKEN BY�� �/
Thia ia to certify that the informaGon provided is correct to the best of my k ledge,an und rst d I am responsible for all charges incurred from this npplication.
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SIGNATURE OF OWNER OR AUTHORIZED A T �" `'��j
Rev.1/93
. �
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
` APP ICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME � PHONE NUMBER ���� �S`� S�
ADDRESS � � �P � SUBDIVISION NAME 7D�` 7l�G�
��!'/��✓� l P ,� [� r� LOT #
DIRECTIONS TO SITE�/ f%fJr' �•'�-1 S�� � ��r� r'J � 7 �
�
DATE SYSTEM INSTALLED �� � NAME SYSTEM INSTALLED UNDER �
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �� � �t -
DATE REQUESTED NI FORMATION TAKEN BY /y
This ia to certify that the informatio�provided is correct to the best of my knowledge,and that I under n I m responsible tor all charges incurred from this application.
�
SIGNATURE OF OWNER OR AUTHORIZED AGENT � /�.�
Rev.1/93