912 Howardtown Rd Pe>siYittee,s,--"` ` �..,- +' DAVIE COUNTY HEALTH DEPARTMENT Pit
Name: -��7��� �' `� �- ' �" fc=�" Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
` Directions to property:/li "' {'� `ti L&k5ville,NC 27028 Subdivision Name:
/k f --��f �,.•;.. '� / Y ;Phone#:336-751-8760 Section: Lor.
AUTHORIZATION FOR
WASTEWATER
S STEM CONSTRUCTION Tax Offic�eQPIN:#
AUTHORIZATION NO: 002599 A
p�
**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 FomVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE / #BEDROOMS_491—#BATHS 0#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)4;Nd NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH- ROCK DEPTH LINEAIbfj�
OTHER °/ %4�,r! :aw -^ � T J �.�i-•''1�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT nye
SYSTEM INSTALLED BY:
,
AUTHORIZATION NO. 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
ESSYSTTEM_WILL FUNCTION
�SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 07102(Revised) < U / �p
e«itttee�s-' Y`� DAVIE COUNTY HEALTH DEPARTMENT od 06
Name;'';- Environmental Health Section PROPERTY INFORMATION / ��
, P.O. Box 848
Directions;o"property: '
fr Mocksville,NC 27028 Subdivision Name: - r
r' Phone#:336-751-8760 Section: Lot:'
AUTHORIZATION FOR
"WASTEWATER Tax Office IN:# b
j, I SYSTEM CONSTRUCTION
AUTHORIZATION NO: A Road Name:w yi �J t "
**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)
/ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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
LOT SIZE �� TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW(GPD)_ NEW SITE REPAIR SITE
1-3
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH-_"��:F '`ROCK DEPTH LINEA
OTHER ✓F''+a�'s.'.tr,
REQUIRED SITE MODIFICATIONS/CONDITIONS _
IMPROVEMENT PERMIT LAYOUT
t9
e
/
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:_��Ly i i•��' + /1
D
AUTHORIZATION NO. JPERATION 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 PERI6D OF TIME.
DCHD 07/02(Revised) �_, .C-