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'AUTH6RIZATION'NO: 2 Q 045/1 DAVIE COUNTY HEALTH DEPARTMENT !� ^v 2 �.
Environmental Health Section PROPERTY INFORMATION N,
Permittee's' / ---'w P.O.Box 848
Name' / Mocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760
Directions to property:V f 01- „Gj Section: Lot:
AUTHORIZATION FOR Z
WASTEWATER -
Tax Office PIN:#
:---,- SYSTEM CONSTRUCTION
Road Name: Zip:
**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..
(ln compliance with Article 11 of G.S Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
1
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION U
IS VALID FOR A PERIOD OF FIVE YEARS. U
ENVIRONMENTA HEALTH SPECIALIST DATE ISSUED