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Permittee's- A DAVIE COUNTY HEALTH DEPARTMENT
Name: �- ( " i tdt.�� ( Environmental Health Section PROPERTY INFORMATION
P.O.Box 848
_Directions to property: ' t' i- L` '�' Mocksville, NC 27028 Subdivision Name:
,. . \ t.� G ?�.,,� Phone#:336-751-8760
u1" Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# -
t�
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 003054 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 FonrdAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen-nits.
(In compliance w�Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
{ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�. L1yC� 1 t# ' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH IPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE ASE #BEDROOMS 3 #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 tiles DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE(" 6tik GAL. PUMP TANK&4h—GAL. TRENCH WIDTH TQ ROCK DEPTH �1 LINEAR FT. )'
v� C oil
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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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.
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OPERATION PERMIT '
SYSTEM INSTALLED BY:Cnerl yaw A/117
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AUTHORIZATION NO. OPERATION ERMIT BYi DATE: �0 ZDl
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES IBED ABOVE HAS BEEN 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 kPERIOD
AF TIME..
DCHD 02/02(Revised) �%/V V e I ee ( V J
Permittee's _ .w.. DAVIE COUNTY HEALTH DEPARTMENT
Names
J1 . 1(_ 41- Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property:./ " " Mocksville,NC 27028 Subdivision Name:
' pp l Phone#: 336-751-8760
Pon kgzg_, Section: Lot:
AUTHORIZATION FOR
+ WASTEWATER Tax Office PIN:#SYSTEM CONSTRUCTION - -
lilt.
AUTHORIZATION NO: 0030- 54 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-$ewage Treatment and Disposal Systems)
***NOTICE***THIS.AUTHORIZATION FOR WASTEWATER CONSTRUCTION
:�.Li,• �f '• ( ;'�'�l` I' � j„C !r IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE r! ,--�- #BEDROOMS #BATHS #OCCUPANTSGARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
`LOT SIZE TYPE WATER SUPPLY 1vt DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEf tiOrG AL. PUMP TANK %+ GAL. TRENCH WIDTH:�E ROCK DEPTH_ LINEAR FT.•?CC,"
��'jc l7�uL*rcr
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
�}<+
IMPROVEMENT PERMIT LAYOUT
i {
� ; r
l ✓
t
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. ;
i
OPERATION PERMIT / ���/I�
SYSTEM INSTALLED BY: C _riI� �IJ
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AUTHORIZATION NO._�� OPERATIOPERMIT Y: DATE: �D
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESC IBED 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) l'�t [�'!.•� .:J'(�'r . . _-%/`/V I)�l?�i (J�F}