124 East Water St � �y�
ermittee's '- � -'� DAVIE COUNTY HEALTH DEPARTMENT ��`"�
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, Name:. '"� �r' '��.'• + �--.--� � ':' �, � Environmental Health Section PROPE�TY�NFORMATION
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•� /,�,,��f l`� �F,. .l '-,/� P.O. Box 848 / /3 3
Directions to property:.r!'�f�` ,.�'r"�-='r� !'%�:'1✓r'j`' Mocksville,NC 27028 Subdivision Name: '
- � �' ' Phone#: 336-751-8760
��'. � r':;i;%,';�'.r' j' j-', f'�,/�� Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTF.M CONSTRUCTION - -
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AUTHORIZATION NO: �'"k�'``��" A Road Name: Zip:
**NOT'E**This Authonzation for Wastewater System Construction 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 compiiance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
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�_�;'. �'!�f�r"' -'� �C'�r �, C„� ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
,�` ��'�''"!�'�-.! 'i, i�� �'����� ��% �� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALT SPECIALIST DATE ISSUED
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RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEDROOMS �%}�BATHS�#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 �✓,
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SYSTEM SPECIFICATIONS: TANK SIZE• GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH� LINEAR Ff. �/l�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PER�IIT LAYOUT �
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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 � '
SYSTEM INSTALLED BY:
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AUTHORIZATION NO._��1'f✓�'��PERATION PERMIT BY: `�"— ! DATE:
•*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
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