167 Liberty Rd (2):
Permittee's, AVIE COUNTY HEALTH DEPARTMENT
Name: ` Environmental Health Section PROPERTY INFORMATION
� Lo 1 P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
I Ct 7 Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
G( it tt WASTEWATER Tax Office PIN:#3 7 I -f t{ o-`?41rCi
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002942 A Road Name: '` L� Zip:dze
**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 1 I of G.S. Chapter 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�` GY •'�� IS VALID FOR A PERIOD OF FIVE YEARS.
NVIRONMENTAL HEALTH SPECIALIST DATE ISSUEAD
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
( G C
LOT SIZE da TYPE WATER SUPPLY l 0 DESIGN WASTEWATER FLOW (GPD) 6 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��/ ROCK DEPTH -�- , . LINEAR FT. �W
R �j c.. G n � d 4 c� G� "� � ✓h � -�� d a1 -5 / (-Q
REQUIRED SITE MODIFICATIONS/CONDITIONS: �Q P 7 c-/ P -T-)'to 1/q r, 0 f. -
IMPROVEMENT PI RMIT LAYOUTvi �()'Ix
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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.
OPERATION PERMIT
LI �SY NSTALLEDBY:
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AUTHORIZATION NO. - OPERATION 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 13,OA, 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 0= (Revised)
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Pen_nittee's r Cl AVIE COUNTY HEALTH DEPARTMENT
Name: U-2- Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: G 7, Mocksville, NC 27028 Subdivision Name:
sr Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
►1 C! ! ' L4 ys t 1 WASTEWATER
SYSTEM CONSTRUCTION Tax OfficePIN:#6 7 4&
AUTHORIZATION NO: 002942 A Road Name: � F'� � Zip:.
**NOTE"'41iis 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
/7`'.�d ' - / IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE A# BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY ` eo DESIGN WASTEWATER FLOW (GPD) 3& G NEW SITE REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE Y 4 GAL. PZJM5
P TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT.
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REQUIRED SITE MODIFICATIONS/CONDITIONS: �`� F �� l Cr G % '!""
IMPROVEMENT PERMIT LAYOUT
C`3
,'}• ,t�� � `h/ tom.
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 Y �A I7
INSTALLED BY: � /l/I � ` /�y ` �N S
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AUTHORIZATION NO. ` �/1 OPERATION 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 PERIOD OF TIME.
DCHD 02!02 (Revised) &9q / �/
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