P2273A McClamrock Rd T'..R,j ..�/ :--rn:r ...v.-r.'a-=za..i, K - - �.i_f - . e - -- - - • --- r C S- •.-: _ _
Penni ttee s 'DAVIE COUNTY HEALTH DEPARTMENT
Name:. ✓� re`i t"'' �`'�a -. y�,,I Environmental Health Section PROPERTY INFORMATION
P.O,Box 848
Dict ns to•property: �'` �= t" r.,j �,'>!r,�i�r%`'%. Mocksville,NC 27028 Subdivision Name:
Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 2275 ' 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 Sewage Treatment and Disposal Systems)
�, r�,l)v ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER'CONSTRUCTION
L YH�SPALIST DATE SSUED IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONME
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS #BATHS_{Q #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
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�_ �OCK DEPTH Jy LINEAR FT. A
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r-
**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
SYSTEM INSTALLED BY:
qlj
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 SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DMD 02'D2(Revised)
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