147 Pudding Ridge Rd AUTHORIz^TION NO: 0614 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMA'
ermitted.s P.O. Box 848 Ug("H6.:5
IName: !�`Jf'/) i�i';%)f'i� Mocksville,NC 27028 Subdivision Name:
. Phone#:704-634-8760
irections to property: 1f ✓�'fii�%r, th' �/i: Section: Lot:! �' AUTHORIZATION FOR
/✓ WASTEWATER Tax Office PIN:#�� �/ �l
/\ SYSTEM CONSTRUCTION
Road Name.
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building
Office when applying for Building Permits.
I (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CO
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
i
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS�#OCCUPANTS $/ GARBAGE DISP
COMMERCIAL SPECIFICATION: FACILITY TYPE f� #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL W
LOT SIZE S J C' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) Tl (!) NEW SITE ! !:� REPAIR S
t
SYSTEM SPECIFICATIONS: TANK SIZE ZMJLGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINE
LINE
OTHER f1e1I L�1.�: . /�l•fitc� '�.8'C�r'�s
!i REQUIRED SITE MODIFICATIONS/CONDITIONS:
1
IMPROVEMENT PERMIT LAYOUT
s
f�
f
h
**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(704)634-8760.
OPERATION PERMIT
Iti L SYSTEM INSTALLED BY:
,/,' V J, V
UW rip ve
S
AUTHORIZATION NO.IN(9 d OPERATION PERMIT BY:� / DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMP
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)