304 Dyson RdPgnnittee'�r �1,' /'�' �,. DAVIE'COUNTY HEALTH DEPARTMENT � �—`•1�� — C�
Name: �' r //" '" �,� "l' Environmental `Health Section ROPERTY INFORMATION
..- P.O. Box 848
Directions to property: �, '� max-✓- 52 ocksville, NC 27028 Subdivision Name:
Phone #: 336-75178760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 2340 A Road Name: Zip:
**NOTE** This Authorization for Wastewater System Constniction 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 compli ce with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f,
r'" ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.•v �," .C.r'"�;�; s ��: ��-�',%:.; ;•r f`�✓ IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOM # BATHS /i OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD: .NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"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)75178760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION N0.PERATION 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 01102 (Revised)
N