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'Pernuttee's � DAVIE COUNTY HEALTH DEPARTMENT
`Nam�: " ����� �'ri r'� ��C�• ��� `�� Environmental Health Section PROPERTY INFORMATION
� `'� °�• , � - P.O. Box 848
Directions to property: � •' �� � �� -� '` `�t- Mocksville,NC 27028 Subdivision Name:
i^ . ; � Phone#: 336-751-8760
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Section: Lot:
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- SYSTF.M CONSTRUCTION ���
AUTHORIZATION NO: ����=�:► � i �.. � ` t.',,�c�.,_,` •.. r. „�
� A Road Name: � Zip:� �� �• ��
**NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Permi[s.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 1] of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
` '' /� ^'' +""�< f ***�IOTICE***-THIS AUTHORI7,ATION FOR WASTEWATER CONSTRUCTION
`'��;'�'� �-�� •� �°`,��!�'"��{,:� �,�`~ /�/ /,;�`j'"� IS VALID FOR A PERIOD OF FIVE YEARS.
ENV[RONMENTAL HEALTH SPECIALIST DATE ISSUED
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 `.b DESIGN WASTEWATER FLOW(GPD) � �� NEW SITE REPAIR SITE //
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SYSTEM SPECIFICATIONS: TANK SIZE � GAL. PUMP TANK,��iT_GAL. TRENCH WIDTH � � ROCK DEPTH� LINEAR FT. c�• G
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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IMPROVEMENT PERMIT LAYOUT �
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FOR FINAL INSPECTION OF THIS SYST'EM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
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AUTHORIZATION NO. �G� OPERATION PERMIT BY: ������ DATE: � �
••THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMP IANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE T KEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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�= `Perniicte,�''e' . � , DAVIE COUNTY HEALTH DEPARTMENT `',
���y �`-'� � '�` '.:� i ; �' �# � "1% Environmental Health Section PROPERTY INFURMATION
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�' � - `� P.O. Box 848 �
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Directions to p�npertyc ` ' ' 1�locksville,NC 27028 Subdivision Name: ,
' Phone#: 336-751-8760
' ' " ' � < Section: Lot:
AUTHORI7,ATION FOR
. � ', _ 4 .�, ti'` ;' f.�' WASTEWATF,R Tax Office PIN:# '-z :.: _:� �.�,.; r�
— SYSTF.M CONSTRUCTION ' �
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AUTHORIZATION NO: Q���'��� A Road Name:� � ' Zip:`�,-`' �� '
**NOTE**This Authonzation 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 pre�ented to the Davie Counry Building Inspections
Office when applyina for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
- : � j r'-r ' ***VOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
. "' '' ; /` �' '�� . F° `r;,.� �, �,, � f� �' .. �j� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECfALIST DATE ISSUED �
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RESIDENTIAL SPECIFICATION:BUILDING T E � � #BEllROOMS � #BATHS #i OCCUPANTS GARBAGE DISPOSAL:Yes or No
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COMMERCIAL SPECIFICATION: FACILITY TYPE #pEOPLE #PEOPLEJSHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
;�.1_r:J /� � --- :'
LOT SIZE � � TYPE WATER SUPPLY �tJ (� DE$IGN WASTEWATER FLOW(GPD) �C� G NEW SITE REPAIR SITE �
� ; � , . A r:� r} � !
SYSTEM SPECIFICATIONS: TANK SIZE !� t Ct GAL. PUMP TANK���.,,,f-1GAL. TRENCH WIDTH � �� ROCK DEPTH � �1 LINEAR Ff. =% ' �
, �� ��. .. � � �
OTHER �
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REQUIRED SITE MODIFICATIONS/CONDITIONS; � +
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, FOR FINAL INSPEGTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTAL.LATION,,��LEPHONE#IS(336)751-8760.
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AUTHORIZATION NO. � OP RATION PERMIT BY: / O%��'/��G%���-`t/ DATE: � �
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**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPI,IANCE
WTfH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE Tt��KEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
` � � APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME_ _ ��. '�' � � �� �� �G �I `'� PHONE NUMBER ���1 �`�'� ��( � �
ADDRESS ' d� l � W �� C� �� t _c.%c^;/.-I � ' SUBDIVISION NAME
LOT #
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DIRECTIONS TO SITE r � :� ' �� �
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DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER �_) � C-��
TYPE FACILITY � NUMBER BEDROOMS � NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY C U SPECIFY PROBLEM OCCURRING ��•.. � 1 � -�' �i� .-f'�":"t �,.-
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DATE REQUESTED � ` ' � ~� / INFORMATION TAKEN BY �C�c�l �%1 .��!^r�� �� r �-�1 �`—•
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responaible for all charges incunsd from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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