198 Greenhill Rd Perm't1.tee s DAVIE COUNTY HEALTH ENT
il&me: Environmental Health Section' PROPERTY INFORMATION
/ P.O.Box 848
Directions to property:T .�':`f;i �� �}Mocksville,NC.27028 Subdivision Name:
Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
.� SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: ARoad 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.]900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
&AAN4' �Z �
IS VALID FOR A PERIOD OF FIVE YEARS.
$4VIRO MENTAL HE L�PECIALIST DATE 1 SUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS.#OCCUPANTS_GARBAGE DISPOSAL:Yes or Noy
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 /!5 LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUToil
14 t I
*"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 f�' ^
SYSTEM INSTALLED BY:. W
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,+3
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L.
AUTHORIZATION NO.%k_OPERATION 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.
DCHD 02102(Revised)
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