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2404 Milling RdPernuttee s DAVIE COUNTY HEALTH DEPARTMENT ame: t..(�,.} }_.c >.1..:r, Environmental Health Section PROPERTY INFORMATION l "` .,�► , �> 5, P.O. Box 848 12 d y _ .2L �Z (j I Directions toro ert V : 1 \ i L 1, I } ( P P Y Mocksville, NC 27028 Subdivision Name: t Phone #: 336-751-8760 I.: -AILS L.�'"3. Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION r �*u AUTHORIZATION NO: 2'a)' C 0 A Road Name "' � L 1 �JZrp **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)„of"Cr,S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTHSPECIALIST DATE ISS ' ED r � r RESIDENTIAL SPECIFICATION: BUILDING TYPE �jW�# BEDROOMS "' #BATHS #OCCUPANTS �` GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE 'L' ?�I"1` _ YPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH i i' LINEAR FT. 1 OTHERt Sl rL►C �-f 1i `� L S l 1 REQUIRED SITE MODIFICATIONS/CONDITIONS: ! �T�1-t t ���7� +✓� t �jt? ` �� rF `�I'"� `'��%�yj Vf-C L 1..�, S IMPROVEMENT PERMIT LAYOUT V Z x 7.)kS41L b L -I -S G. = U -M ST1,, C • -��:=-S s�y..VSTIrJ� �L�Tv`r'` t(w As tJILL Li: OVIC.0 **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: /V r S L R to "iD ti a- Iz-avy L:Lj, CLA OT AUTHORIZATION NOv OPERATIONPERMIT BY: p 7 1,W10 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA THEMYSTEDERIBED ABOVE HA N INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE ATMENT 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/0�5 ,. , � ���I.b �` r �' ^��� � � ��^�� � ���"� r s �i�'�� � '�'i t w �7 ,. � � q,� ��.� m.� �� �� gs:�a�S� s���«3 ��' ' ��� �� �i� "��§ a� �"` �� �Ci � �,. 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