309 Harvest WayPennittee's DAVIE COUNTY r ,
HEALTH DEPARTMENT: 30
Name, Tom• �„,-- Environmental Health Section PROPERTY INFORMATION
F jn P.O. Box 848
Directions to property:p21I 1 Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
1 A0A 4 V'_16: .. CU -Ir Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 2186 A Road Name:
**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 corttpltlnce with Article I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
y_._.
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
C�
_ IS VALID FOR A PERIOD OF FIVE YEARS.
ON `TA H ?H SPE ALIS DATE t SUE
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) 3Lr LE�NEW SITE 'REPAIR SITE V
W/�
SYSTEM SPECIFICATIONS: TANK SIZE !t6 �L. PUMP TANK GAL. TRENCH WIDTH 31,� ROCK DEPTH 12 LINEAR FT. 100
'OTHER_/G'� -A Aj i'11 �" `i S�l:.J
REQUIRED SITE MODIFICATIONS/CONDITIONS: ��) ti 3c'7 t
**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
SYSTEM INSTALLED BY:
-TM k .
AUTHORIZATION NO. 2t liL OPERATION PERMIT B DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYLVDESCRLIBED ABOVE EEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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 02M (Revise
t`
• I la�i�� - �,�,�1�v-Ach9R (o(ll
• V COMPLAINT FORM
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
Date Received
57--7—a.3
Name of Complainant iJ t •1 ti 8 e e Received By
Address LL Teleph ne
Complaint
aLS o 4--u l=� L, xi:. C.f'•• e O
L
n _ 40 twvtw
rutin-cwt.. r --»
Person Responsible for Complaint ^ OL^j
Address Aj",9S' T l� I -w Telephone % 15:,(— 5— y
Directions to Complaint
1 S r aes C -4--e s ,@ _1> e,.l f -^4t, ,re •. • -w -S
Date Investigated Investigated By
Complaint Justified Complaint Not Justified
Action Taken ab t-� Ak-c-.3b D'f'c-6
• C,t� u
Date Environmental Health Staff Signature
(DCHO 1/85)
x
ow
...
8464
i
a
4 �
E yy 4
8,E M
�P '
T
44
It
R
r
r
c
r�
1 A
174C
�T �q� `fib„ «';A � Y,y•z. :
t
81 �y
Iq
w
t
z
i n
a �a`
�S �
Gi