579 Pudding Ridge Rd• GcJ
rmiiT tee -1.1} _ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: -� 1 r I t-,"^' + Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
LA
AUTHORIZATION FOR
:` t t'' E...� { I i'��•, s (.3 �.. .� +. e .� 1i! WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 277 A
Secti
Lot:
Tax Office PIN:# -
Road Name "` Zip:a7_
**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.
TH SPECIALIST' DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 1)V) KA" # BEDROOMS 3_ # BATHS 7— # OCCUPANTS 7-- GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TY`P�E'� # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE `* ' YPE WATER SUPPLY ` `�'` �" DESIGN WASTEWATER FLOW GPD �t� V V1
( ):7 NEW SITE REPAIR SITE
11 I, I
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH - ' ROCK DEPTH 11- LINEAR FT. UD
REQUIRED SITE MODIFICATIONS/CONDITIONS: r` U---� 0 r 0`
I IMPROVEMENT PERMIT LA
1...1r.�C�:.-�•1G��- Kai='-�..�.`�,,
"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: Z -V
CV
i
AUTHORIZATION N0. ERATION PERMIT BY: DATE: '� Zo
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 02102 (Revised)