963 Farmington RdDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
bisections trlproperty: / S /�7� lll."' l i Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section:
i AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# !!i✓�' �""-
r� SYSTE CONSTRUCTION
AUTHORIZATION NO: 2 1 A Road Name /6 Zp:
i
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSU 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 11 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
/ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ;q
(�' •�� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMSI_,: 7 # 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
SYSTEM SPECIFICATIONS: TANK SIZEe!!PGAL. PUMP TANK GAL. 'TRENCH WIDTHy k ROCK DEPTH LINEAR FT. 41 /9�
OTHER ' l�%
REQUIRED SITE MODIFICATIONS/CONDITIONS: _
"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:
N-�/�AUTHORIZATION NO. S�Z�� OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE -HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 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.
DCEiD 02102 (Revised) O —705
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
i
PO Box 848/210 Hospital Street
.` r. MocksviIle, NfC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER F�'�'� - FOR DWELLING
{ . } (Check One) REPLACEMENT ❑ R MOIFAB G ❑ RECONNECTION ❑
/ k
Name: l& / Lz JJ ea 4-5 Phone Number:1 '�3� q� 9 i�" %�3$8 (Home)
MailingAddress: %Jr �a r !til 1 116 4or1 (wo*)
e k,,:; i); AJ. I'_ Q 9 d
...Detailed Directio
Property Address: 96,3 /—n f m 1 VIA
fR c� 1I r 1 oc_ CS U 1 1 e VV90081 '
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under:./�� in I a 5Po YS Type of Dwelling: '
e�
Date System Installed onth Da Year : a Number Of Bedrooms: Number_ Of People: 2
Is The Dwelling Currently Vacant? Yes ❑ No Yes, For How Long? '
Any Known Problems? Yes ❑ No If Yes, Explain:
Please Fill in The Following Information About The New Dwelling•.
Type.Of Dwelling: . tai Number Of Bedrooms: Number Of People:
�. Reg4ested $y: _ �1/2A . � Date Requested
(Signature) i
For Environmental HealthLOffice Use Only
Approved Disapproved ❑ r..
Comments: �/nlL` S iiQG S�UDEx: D of " 4CI� � �1Jt+.t �'/nl -T4h)V-
�41�n (_WC -S !� %7Tt�D ,Lew A2 ccs k
`6 Environmental Health Specialist Date
*The signing of this form by the Environmental ealth Staff is in no way intended, nor should betaken as a '
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
- r / i o i
Payment: Ca''shnn❑ Check oney Order ❑ #�= l .�� 2,Amoannt: $ d • Date: --�
Paid By:
'Receiv'e d By
Account #: f ` Invoice #':
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