276 Richie Rd FTmittee s ;i"&V,1E COUNTY HEALTH DEPARTMENT
Name: ,ate d',� '.�'" i"",�'s✓ '' .�s�'</ e' Environmental Health Section PROPERTY INFORMATION
P.O.Box 848
Directions to property �G f iMocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760
✓ ./ ! ,:r a.r' /r Section: Lot:
AUTHORIZATION'FOR
WASTEWATER Tax OfficePlN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: `'" 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 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
r ) ,
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
E VIRONIvIENTAL HEALTH SPECIALI DATE ISSUED
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
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) �' NEW SITE REPAIR SITE_
SYSTEM SPECIFICATIONS: TANK SIZE�_GAL. PUMP TANK GAL. TRENCH WIDTH"� 47 ROCK DEPTH INEAR FT.
OTHER = " V
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL IN=IS (336)751-8760.
F THIS SYSTEM
BETWEEN 8:30-9:30`A.M.OR 1:00 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHON
OPERATION PERMIT
SYSTEM INSTALLED BY: Ott otkl
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AUTHORIZATION NOCig`—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 07/02.(Revised)