203 Four Corners RdAUTHORIZATION No. 1792DAVEP, COUNTY H>ALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's %'� e (Si P.O. Box 848
Name: Mocksville, NC 27028 Subdivision Name:
Phone # 336-751.8760
Directions to property: Section: •
t (.} (^• Ct r`�3 +: .: /1� ,Lot:
AUTHORIZA.
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TION FORAq
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WASTEWATERTax Office PIN:# '_
SYSTM CONSTRUCTION
oRoad Name: Zip.
*"NOTE" This Authorization for Wastewater System Consiruciion MUST BE -ISSUED by the Davie County Environmental Health Section prior
to issuance of.any Building I?ermits: This orm/Autllorization Number should be presented to the Davie County Building Inspections „
Office when applying for Building Pemvts.
(Iii compliance w th Article 1 l .of,G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f .-�... *4.NOTICE*"" THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r:
�'`-"` C s. _.•- ^'" $ I'TLS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONHEALTH SF}ECIQLiST
DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE�f�S�$ BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL. Yesnr No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE`TYPE WATER SUPPLY C /W'y DESIGN WASTEWATER FLOW (GPD) . NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK. GAC.. TRENCH WIDTH. f.. ROCK DEPTH I' LINEAR Fr. 7I .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
114PROVEMEN7 PERMIT LAYOUT
**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:
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A RIZATION NO. %�%� OPERATION PERMIT BY: GATE:
UTHO-�L—F-1
*'TYRE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM' DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I L 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.
UCHD 051% (Revised)
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