287 Yadkin Valley Rd /� JC O
AUT�j�3R_?�3TION NO: O 7 O�J DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section PROPERTY INFORMATION
perm��ee'���..# '�/ � P.O. Box 848 /�/ ' � �C
Name: _,�..r� �/'=�/'7_�� �r Mocksville,NC 27028 Subdivision Name: !/ ��/ �
: � Phone#: 704-634-8760 �
Directions to property:-:.'�%` �•' Section: � Lot:
. �- ; AUTHORIZATION FOR
`` WASTEWATER Tax Office PIN:#
, SYSTEM CONSTRUCTION �r� - -
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**NOTE**This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts.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
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�, ' ��•{ � , �-�;` ' ��. � -� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS �� #BATHS �.5"'�� #OCCUPANTS ��� GARBA
�� ��� �� GE DISPOSAL:Yes or No -
COMMERCIAL SPECIFICATION: FACILTI'Y TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No'
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIIt STfE �_
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SYSTEM SPECIFICATIONS: TANK SIZE����% GAL. PUMP TANK GAL. TRENCH WIDTH �-�:� � ROCK DEPTH�� �f LINEAR ��� � �
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OTHER
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REQUIRED SITE MODIFICATIONS/CONDITIONS: ��_� �..
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IMPROVEMENT PERMIT LAYOUT ' �{ �
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**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 TI-IE DAY OF INSTALLAT'ION.T'ELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
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