121 Foster Dairy RdPermittee's DAVIE COUNTY HEALTH
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('� H DEPARTMENT
Name: ��'-►''-�' Environmental Health Section PROPERTY INFORMATION
j P.O. Box 848
Di tions to ro ert : , //-tJ' �:; '
P P Y o fy f1 , � � � h1ocksville, NC 27028 Subdivision Name:
' Phone #: 336-751-8760
�.����; ,; .•-�,.. jy '�,�''; � Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION NO: .,p A Road Name: Zip:
**NOTE** 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/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
i
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
' IS VALID FOR A PERIOD OF FIVE YEARS.
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ENVIRONMENTAL HEALTH SPECIALIST 'LTE ISSUED
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 AT/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH/ LINEAR FT
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 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
I OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. ��-•'� PERATION PERMIT BY: U` DATE:y!
*"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 02/02 (Revised)