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Permittee s-'' ,��` DAVIE COUNTY HEALTH DEPARTMENT P �`/
Y�ne;� �'+..�`�!"��s�� �. `4`-s,`i`:; '' � Env�ronmental Health Section PROPERTY II�1FORMATION
a� ,, P.O. Box 848
Directions to property: ��°'' f��.';',+�/r� �...',�`'�' Mocksville, NC 27028 Subdivision Name:
�� � Phone #: 336-751-8760
r'",�,,�r•�'� �` �-� . ���" „ ��,� ,��r Section: Lot:
AUTHORIZATION FOR
- WASTEWATER Tax Office PIN:#� -
� SYSTF,M CONSTRUCTION -
AUTHORIZATION NO: �� d'�� �`' `�' A Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Healt ction prior
to issuance of any Building Pe►mits: This Form/Authorization Number should be presented to the Davie County Building Insp ions
Office when applying for Building Permits. �
(In compliance with Article i l of G.S. Chapter 130A;-�astewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
� ` 'r ¢ 4 �/ � 1 �, � ���` � �:' ,,�,y ..i � � y ***NOTICE*** TH S VALID OR ATPERIOD OF IVE YEARS. CONSTRUCTION
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
: RESIDENTIAL SPECIFICATION: BUILDING TYPE �✓%�`�� # BEUROOMS �# BATHS �> # OCCUPANTS �� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No
L(3T SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ����-% NEW SITE REPAIR SITE �-�-•'""""��
� � � �j � / 7
SYSTEM SPECIFICATIONS: TANK SIZE GAL. P.UMP TANK GAL. TRENCH WIDTH r ROCK DEPTH � LINEAR FT. _,'�°�'
� �. �., ..
, � � ����
OTHER '�(.�� �'��'�� c_J �� ^.
REQUIRED SITE MODIFICATIONS/CONDITIONS: • �� �
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IMPROVEMENT PERMIT LAYOUT
4)�••
.......
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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 THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
r
SYSTEM INSTALLED BY:
, . . ' . . .. . . _ e � . ' .
' �AUTHORIZATION NO.��� OPERATION PERMIT BY: DATE: ���/
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
V�TTH ARTICLE 11 OF G.S: CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
G[JARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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