185 Will Boone Rd (2) Perr.�ittee's,,fa , ---- DAVIE COUNTY HEALTH DEPARTMENT �� 3 �"9 � �
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Name: J � . �-,+ '~�-��j�11���� Environmental Health Section PROPERTY INFORMATION
/r,,� r 1 f P.O. Box 848
' . ' Di�ections to property:/ �}3 �•�/',''•'���='a�' �`�� Mocksville,NC 27028 Subdivision Name: '
� � % j� � Phone#: 336-751-8760
/���,"�'� 1`� S`�� .'': L �; �� Section: Lot:
AUTHORIZATION FOR
WASTEWATF.R Tax Office PIN:#
SYSTF,M CONSTRUCTION -
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AUTHORIZATION NO: A Road Name i
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section pnor
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. '
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) '
'i: .� � ,%�) ' /' � ,���" ,�� � , ,. ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION '
J�'f1'.�� �;" /�`�.•"+--G�( .)' --/ 1? '�.� IS VALID FOR A PERIOD OF FIVE YEARS.
� ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE�_ #BEllROOMS � #BATHS �� #OCCUPANTS`�_I GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
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LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) �/ +� NEW SITE REPAIR SITE �
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SYSTEM SPECIFICATIONS: TANK SIZE �'`�'�GAL. PUMP TANK GAL. TRENCH WIDTH `^• � ROCK DEPTH �"+ LINEAR FT.� �r
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
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 ��^, (���_ �'�
SXSTEM INSTALLED BY: CH�'� �6
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AUTHORIZATION NO.�OPERATION PERMIT BY: DATE:
trTHE 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.
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