421 Becktown Rd 4 . . � - . ,." . .. � - . - . . . . � .. . , � . . � . . . . . . . . . . . . .
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- `Permittee's ..•—. // DAVIE COUNTY HEALTH DEPARTMENT
Name: '*�-��-1� ,.`���e/� '/,«'3 Environmental Health Section PROPERTY INFORMATION
� � 1 i / P.O. Box 848 �
Directions to property: ���� �t'�r`�t"�f�tj1 i�?"�/ Mocksville,NC 27028 Subdivision Name:
,� J �,r�j�;� (��' Phone#:336-751-8760 Section: Lot:
o"�/�f" ,_. - �...,, �" r/,
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
� SYSTF.M CONSTRUCTION - -
AUTHORIZATION NO: �'�'� � �'� A Road Name: Zip:
**NOT'E**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/Authonzation Number should be presented to the Davie Counry Building Inspections
Office when applying for Building Perrnits.
(ln compliance with Article 1] of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/ ��' ,, '/' ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
�;��>/" a;/'`���//' y:..��""'`j �`��, �,''-�='���'r-� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIFFONMEI�T'AL HEALT "SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS;�#BATHS�#OCCUPANTS �* GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) r''--���� NEW SITE REPAIR SITE�
/ „ /
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH l.�^� ROCK DEPTH�LINEAR FI'�=�,�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT rd
SYSTEM INSTALLED BY: ��
uV �
AUTHORIZATION NO.�_���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 07/02(Revised)
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