124 Center Circle Lot 31**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 the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
tj/� (rte 7 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
p - IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFF # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE O• TYPE WATER SUPPLY (O DESIGN WASTEWATER FLOW (GPD) 366 NEW SITE REPAIR SITE _
SYSTEM SPECIFICATIONS: TANK SIZE = yt SGAL. PUMP TANK N / L GAL. TRENCH WIDTH ROCK DEPTIO LINEAR FT. 3 a 7 I
AA, lll!!! 11
OL( a5z)
REQUIRED SITE MODIFICATIONS/CONDITIONS:`�-
I '
IMPROVEMENT PERMITLAYOUT ` ' .•S.
.� vNb�r J 11
r i IN
31
I �
{ � 47
ILFOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
1
AUTHORIZATION NO. 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 0702 (Reviud) , I A A 1+ [n% Li K
Permi s j
i r / DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
PROPERTY INFORMATION
/ /
c-"' V� 1 /C/
P.O. Box 848
(�
,- Directions to property:
Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760
i
Section: Lot: 5
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I
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(',v s' C, N Rls-'
AUTHORIZATION FOR
WASTEWATER
,C t/
Tax Office PIN:#/`'�!�-
AUTHORIZATION NO: 002927 A
SYSTEM CONSTRUCTION
I I L-( C r,.*I f_?p
Road Name: I / � � ZiDO —7 �C
**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 the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
tj/� (rte 7 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
p - IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFF # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE O• TYPE WATER SUPPLY (O DESIGN WASTEWATER FLOW (GPD) 366 NEW SITE REPAIR SITE _
SYSTEM SPECIFICATIONS: TANK SIZE = yt SGAL. PUMP TANK N / L GAL. TRENCH WIDTH ROCK DEPTIO LINEAR FT. 3 a 7 I
AA, lll!!! 11
OL( a5z)
REQUIRED SITE MODIFICATIONS/CONDITIONS:`�-
I '
IMPROVEMENT PERMITLAYOUT ` ' .•S.
.� vNb�r J 11
r i IN
31
I �
{ � 47
ILFOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
1
AUTHORIZATION NO. 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 0702 (Reviud) , I A A 1+ [n% Li K
' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
DIRECTIONS TO
%ah.�L, l3riClG,
/e
PHONE NUMBER 9z-19r31.r
SUBDIVISION NAMEJfhgXl9fa P</tw
LOT # V _�
.S gap agtaOWNer //-/p//f/r' -
DATE SYSTEM INSTALLED d 71 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY -#d SZ NUMBER BEDROOMS NUMBER PEOPLE SERVED l
TYPE WATER SUPPLY well SPECIFY PROBLEM OCCURRING A/(W -A&Ao
DATE REQUESTED S -09 - INFORMATION TAKEN BY,
This is to certify that the Information provided is coned to the best of my knowledge, and
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. 1193 / A /ra I 'e AQ i✓ i-QL>r//�i'(i
� (71 GfiY1/f1i!
I am responsibi ;or
all ch as incurred from this application.
Pemur,:e's1
A,,
/
! DAVpiE COUNTY HEALTH DEPARTMENT
ZOU//O"
Name: d 4;/0!�
Environmental Health Section
P.O. Box 848
PROPERTY INFORMATION
j/+
h1
1 w /f/
Directions to property:
Mocksville, NC 27028
Subdivision Name: P f 1
t-
Phone #: 336-751-8760
'
Section: Lot:
- !
O i
GU S v
U H
AUTHORIZATION FOR
WASTEWATER
@ t/
Tax Office PIN:#j 151 L� ") S 3 {
AUTHORIZATION NO:
002927 A
SYSTEM CONSTRUCTION
/), Lf C l �✓
Road Name: CII �'s Zip; �Qa
**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 FomVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In comeliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
7— O7 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST, DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 51 # BEDROOMS J� # BATHS � # OCCUPANTSGARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE O • j5 +6 -TYPE WATER SUPPLY (0 DESIGN WASTEWATER FLOW (GPD) 36 Q NEW SITE - REPAIR SITE
SYSTEM SPECIFICATIONS, TANK SIZE r �(SiAL. PUMP TANKN / YY GAL. TRENCH WIDTH ROCK DEPTgjW LINE,nR FT.3 A7 /
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT AV.
r V)
\b v1O
i�
�s 9
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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.
DCHD0=fthKel A,.Lr%: 1/Jti