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�,;Pe�mittee's�:> DAVIE COUNTY,HEALTH DEPARTMENT /�� �"'�v ` �.� �
r �� Name:��'� ��r i =�`.. � ��'r.�1,=�, Environmental Health Section PROPERTY INFORMATION �
_ /�.�'�'� P.O.Box 848 :
Directions to m ert,: f l _•-* /,•;:%i.lf,�,�/ ��.
P P Y � Mocksville,NC 27028 Su6division Name:
�� , ��,; ` ' � ` Phone#:336-751-8760 _ ;,
,.,, �l;� f �• ' ' '"�✓-�'- �f�,-� ,� ,.�' C� Section: Lot: ,
_ r,, /�-. �;i j�� AUTHORIZATION FOR '
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��� � SYSTF,M CONSTRUCTION /� �IUO-�-I��-`,�.Z": Z!Q~`-'v
' ALJTHORIZATION NO: A Roa ame: ��' �p
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior � '
ro issuance of any Building Perrnits.This Fomi/Authorization Number should be presented to the Davie County Building Inspections ,
'Office when applying for Building Permits. �-
` (ln compliance with Article l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�;;a / ; - �-�� ;„ ,�r ,�� r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�,' r �'� =.r,' . ��:1�• „�'`j i) � ��< ' �� " IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALT�i SPECIALIST bATE 1SSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE � #BEDROOMS� #BATHS � #OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFf #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPI,Y DESIGN WASTEWATER F[.OW(GPD) �`�`"�NEW SITE REPAIR SITE�_✓
SYSTEM SPECIFICATIONS: TANK SIZE . GAL. PUMP TANK GAL. TRENCH WIDTFi�� ROCK DEPTH ��L NEAR Ffl.k��
OTHER . _
REQUIRED SITE MODIFICATIONS/CONDITTONS: ' '
IMPROVEMENT PERMIT LAYOUT
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*"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH bEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT ' \�� � �
SYSTEM INSTALLED BY: �
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AUTHORtZATION NO. ���4 OPERATION PERMIT BY: DATE: Z O7
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS BED ABO AS BEEN INSTALLED IN COMPLIANCE
WTTH ARTICLE I 1 OF G.S.CHAP'TER 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) . `� ��� �
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��,.-= -�ccc.�'s; � . DAVIE COUNTY HEALTH DEPARTMENT ��. S�a ` � ( �"
-�` ' � ? �'� y �a�•- Environmental Health Section PROPERTY INFORMATION � ,
'� � � _
��<�:Name - �_c -
' �' ' � � P.O. Box 848 -
`' . .�D�ecUons to property: .+��`rr` �a��".' �.;��!f.�''�'�: �f, 'Mocksville�.NC 27028 Subdivision Name:
_. ` , Phone#:336-751-8760
. -- _ ,; f i' r�"d Section: Lot:
- � AUTHORIZATION FOR
� �'� ;' ,{ .. ��� WASTEWATER Tax O fice PIN:# - -
SYSTF.M CONSTRUCTION
AUTHO ~ TION NO: , ��'��' + A :` Rda�l�i'aroSNO(��/�� ,Z�Q�L,�
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**NQT'E**'F,�is Autharization for Wastewater System Construction MUST BE ISSUED`by the Davie County Environmental Health Section prior
'• ' to��ssuance of any Building Permits.This Forn�/Authorization Number should be presented to the Davie County Building Inspections
Of_fice when applying for Building Permits.
�" (In compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) , ,
,!` � ` • ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,,� ! ' '�•; .%"' .�• '' .� , .;-� .•- � •,�':°a,r�,,'' ' , IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE / / #BEDROOMS� #BATHS � #OCCUPANTS�GARBAGE DISPOSAL:Yes or No
�. � .
y COMMERCIAL SPECIFICATION: FACILTI'1'T1'PE #PEOPLE #PEOPLFJSHIFT �i SEATS INDUSTRIAL WASTE:Yes or No .
. � � . ' - •. � r t �
LOT SIZE.` TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) `-��'�NEW SITE REPAIR SITE •�
SYSTEM SPECIFICATIONS: TANK SIZE_�GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH ��L NEAR Ff�� '
OTHER ,
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��. REQUIRED SITE MODIFICATIONS/CONDITIONS: ' � ,,
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IMPROVEMENT PERMIT LAYOUT
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•*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. '
OPERATION PERMIT `� 1 /
. � � � ^� SYSTEM INSTALLED BY; ��' `��N ���.
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AUTHORIZATION NO. --? �I� OPERATION PERMTT BY: ' �/• T � DATE: D7
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•'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS EltIBED ABOV AS BEEN INSTALLED IN COMPLIANCE
W1TH ARTICLE 11 OF G.S.CHAP'TER 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.
DC;HD 01�02(Revise� , � ^� � �/ � � :
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