P2507A Main Church Rd mmuittees ,
; DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
►t P.O. Box 848'
Directions to property: r'G'64) r Z11L,. ,4- Mocksville,NC 27028 Subdivision Name:
Phone#:336-751-8760
�`,r . t Section: Lot: '
�' -7 AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# _
SYSTEM CONSTRUCTION -
AUTHORIZATION NO: , A Road Name: MAC w C 5
, 0,t P
**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.
(Incompliance with Article I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
r' ***NOTICE*** IS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
THIS VALID FOR A PERIOD OF FIVE YEARS.
NVIkO MENTAEALTH SP &LIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT r`#SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWA.T,I R FLOW�G.PD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE -GAL. PUMP TANK '` GAL,-TRENCH WIDTH If ROCK DEPTH LINEAR FT
J
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT 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 >n
SYSTEM INSTALLED BY:
AUTHORIZATION NO.4? '2 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 07102(Revised)
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V-7
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
A LIC TION F R IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
ADDRESS SUBDIVISION NAME ��r��3 /�
>%�� v" ✓ �� LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my know a go,and th rs responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193