163 Oakdale Circle Lot 7 Permittee's _ f DAVIE COUNTY HEALTH DEPARTMENT
1
Name: C �n +G Zr Environmental Health Section PROPERTY INFORMATION (p��
Q I y L f P.O. Box 848
Directions to property: u 11 J Mocksville,NC 27028 Subdivision Name: �r:+ 9� (4,. ct.
IZV IC) OCA 1< eP /Q (,r Tc Phone#:336-751-8760 _
Section: Lot:
/ AUTHORIZATION FOR
_ . Gu S _f' 49jA WASTEWATER L•.. 5�7�1a_ G'3 _ '�'Q�
Ct 5 SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 002960 , A Road Na e:3 G C, � Jt c�I� 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.
(In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�l
,a�// t y�j �✓_- er� 11 ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
`; �r'L� r"✓ Com' C✓ 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 #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No.
L/
LOT SIZE Q�G TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITEy
f �y X40 413 ,
SYSTEM SPECIFICATIONS: TANK SIZE k� GAL. PUP TANK GAL. TRENCH WIDTH ROCK DEPTH I LINEAR FT.
As uated in 15A NCAC 18A.1969j5
OTHER =:pZ d Systems may
REQUIRED SITE MODIFICATIONS/CON ITIONS:
IMPROVEMENT PERMIT LAYOUT `""-
� {C,,d� o-r SSP 1qCPIA/
oZ,(Q� a ,' " 5�-�c-f- �,.r�at ' rt
' O
v` 5 fi-e IM -
lvc{,•v JA o0.
1004
S
C�. GN�
I T 1 \ ��_ ,
3ti �S�ns
ou
• t •s
FOR FINAL INSPECTION OF THIS S. STEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLA E#IS(336)751-8760.
OP RATION PERMIT _
SYSTEM INSTALLED BY:
er
141
70,
c� A
AUTHORIZATION NO. v 4doPERATION PERMIT BY: DATE:del
Z �
**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
�OFTINMtjJE.
DCHD02/02(Revised)
rl�"v
PFrmittee's `j . rr. DAVIE COUNTY HEALTH DEPARTMENT
Name: t ,' ' 4r�r Environmental Health Section PROPERTY INFORMATION b1
�£ Jlj P.O. Box 848
z Directions to property: / Mocksville,NC 27028 Subdivision Name: r
rPhone#: 336-751-8760
e j n ( •f ` C ;
Section: Lot:
t rt
AUTHORIZATION WASTEWATER
OR
t t! ', G « S l �� SYSTEM CONSTRUCTION Tax Office PIN:# -
AUTHORIZATION NO: 002960 A Road Name:'' oc. ct Zip. .r G' '
**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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
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 #PEOPLE/SHIFT / #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE a G TYPE WATER SUPPLY ` Q DESIGN WASTEWATER FLOW(GPD) ��'�` NEW SITE REPAIR SITE V'
Lkrrr, 1 . Ir 'c [i
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PU
&TANK GAL. TRENCH WIDTH T ROCK DEPTH ' LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT (�` U j0,�>� �,•�G` 64
it / 1
�,G fry �i•4� .�
I jV-0
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF iNSTALLATIOITTEEMMUNE#IS(336)751-8760.
OP RATION PERMIT
SYSTEM INSTALLED BY:
O A i
c A
y % ) 3 t
cti
\ AUTHORIZATION NO. DOPERATION PERMIT BY: DATE: �U 7
**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 02/02(Revised)
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