138 Charlie Reeves Rd_.. . ,
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Peimittee's "� `�` DAVIE COUNTY HEALTH DEPARTMENT �� � ^ � � ��
�� Ndme: �,,�,,� :�"�� �'`� �°�/%. �.,�.f" i' Environmental Health Section PROPERTY INFORMATION
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Directions to property: +�'�� � �-- ``% �`� f 1�locksville, NC 27028 Subdivision Name:
£ 1 ',, . ,,„„r ' ' ,�;;� � ;' ; Phone #: 336-751-8760
, I" , r,. Ucr�'3' �•'r.� �.,.,,�✓`G':r =�'f Sec[ion:
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�� AUTHORIZATION FOK
_;�.f/ �'� WASTEWATER Tax Office PIN:#
SYSTF.M CONSTRUCTION —
AUTHORIZATION NO: ���� A Road Name:
_ Lor.
Zip:_
**NOTE** This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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.
(ln compliance with Artide 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
� ,. "� � � �,,s' �,,� �r' 1 � t ***NOTICE*** TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
, ` ;; `�i , `"�.,�,,i` 1^ '�,.�, �;-� �'" '✓ �-^'�- � �' IS VALID FOR A PERIOD OF FIVE YEARS.
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ENVIRONMENTAL HEALTH SPEC[AL�IST DATE ISSUED
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RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS �� # BATHS �# OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE TYPE WATER SUPPLY /,✓� DESIGN WASTEWATER FLOW (GPD) r/ � NEW SITE REPAIR SITE y'�
% (I i� �/ ,�';
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �G ROCK DEPTH .�� LINEAR FT f�'
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IIMPROVEMENTPERMITLAYOUT
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"`*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 930 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT l
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AUTHORIZATION NO. OPERATION PERMIT BY: DATE: `' I��r/
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*'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 0?JU2 (Revised) „/')�� � Q � �
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