1913 Yadkin Valley Rd _ . _
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:rnuccee' --' , DAVIE COUNTY HEALTH DEPARTMENT �`�' �f J
me: Environmental Health Section PROPERTY INFORMATION
� P.O. Box 848
� Directions to property:.�--�'-���"Y" �''1-'� hlocksville,NC 27028 Subdivision Name:
/y � '� f ���`�„ ' � ,��f Phone#:336-751-8760
• �.y , � �i' � :i''.� .!,-:: ; . �` `�' Section: Lot:
�"" j�' ��,:' AUTHOR17.ATION FOR
� �"f ` R'ASTEWATER
��".'� '--' ' •%�=� Tax Office PIN:# - -
, ,;,, v,;, , ' SYSTF,M CONSTRUCTION
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AUTHORIZATION NO: �'��� �'� � A Road Name: Zip: '
**NOTE**This Autharization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any BuildingPernlits.This Form/Authorization Number should be presented to the Davie County Building Inspections ,
Office when applying for Building Permits. �
(ln compliance with Artide 1] of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
,/ '" . ::, ' ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION '
` ` "� � ;<` �'� � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL:HEALTH SPECIALIST� � DATE}ISSUED � -
RESIDENTIAL SPECIFICATION:BUILDING TYPE s""_•�_ #BEUROOMS ��#BATHS ,f #OCCUPANTS � GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF✓SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
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LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)��-✓�l�� NEW SITE REPAIR SITE ��"�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPfH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT
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1 *CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 830-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#'IS (336)751-8760.
OPERATION PERMIT /� o�
SYSTEM INSTALLED BY: y`--f
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AUTHORIZATION NC���s]/-�PERATION PERMIT BY: / DATE: ���� �
�•THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTTCLE 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 SATISFACfORILY FOR ANY GIVEN PERIOD OF TIME.
� DCHD 02/02(Revised) � � �� � ..
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