725 Markland RdPunnitte ass . �� DAVIE COUNTY HEALTH DEPARTMENT
Name: J)lt. ;1) e4 to �r:.f f .•; �G=f�/' Environmental Health Section
P.O. Box 848
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PROPERTY INFORMATION
Directions to property:�lV1ocksville,
NC 27028
Subdivision Name:
DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE
Phone #: 336-751-8760
# PEOPLE/SHIFT # SEATS
INDUSTRIAL WASTE: Yes or No
Section:
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AUTHORIZATION FOR
f'
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�, N�WASTEWATER
Tax Office PIN:#_
SYSTEM CONSTRUCTION
47
AUTHORIZATION NO:
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A
Road Name:
_ Lot:
'Lip: _
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r% IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SP�CIA IST DATE ISSUf?D /
RESIDENTIAL SPECIFICATION: BUILDING TYPE
# BEDROOMS
# BATHS 1y L # OCCUPANTS ;..,GARBAGE
DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE
# PEOPLE
# PEOPLE/SHIFT # SEATS
INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY .'l/P DESIGN WASTEWATER FLOW (GPD)Cy � jNEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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4
"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
W&I0UT 1R&*Yly.V114 -03Ws
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AUTHORIZATION NO. & �41`ERATION PERMIT BY: DATE: �✓ `V
"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)