475 Fred Bahnson Dr (4){ t ;.. t^t -; 7 fj4rxripE..` t ° ..! .x'. � e'ni 1 0': k✓ t ..F � 'iTC ' ''! _ r._. lx P::'>Yr ^'i.:L:n,. ... .-_
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DAVIE COUNTY HEALTW DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT,PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
lIn rompliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME J // 74 PROPERTY ADDRESS �r��Ajtxsail� Ae� DA
LOCATION `'S�o�'I �i�C� SCJ/�/J�/s'o.e✓ ' ,D/—
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS �GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �_ NEW SITE REPAIR SITE L,""
SYSTEM SPECIFICATIONS: TANK SIZE 2�0 6AL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH LINEAR FT. �Q d
OTHER ,/t l��(✓,rM U � Y'��
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE IN DED STERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLI STEM.
A
IMPRDVEMENT PERMIT BY
**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 (704) 634-8760.
OPERATION PERMIT SYSTEM I O
.AUTHORIZATION NO. OPERATION PERMIT BY ��� DATE
**THE ISSUANCE OF THIS ORATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 136A, SECTION .1900 "SEWS TREATMENT AND DISPOSAL. SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FLNJCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
�s r Davie County Health Department
ENVIRONMENTAL' HEALTH SECTION
P.O. Box 665
—M Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM tONSTRUCTION
(Issued in compliance with Article 11 of
- G.S. Chapter 130A, Wastewater Systems)
***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.***
AUTHORIZATION NUMBER LLY
NAME;-11 DATE '"/� '`7 to N2 0 ? 10
NAME ON IMPROVEMENT PERMIT (If different..than above)
SITE LOCATION_y ��L� Ire' � �AiIAfOI✓ �l
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COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*** THIS AUTHORIZATION FOR ASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONAENTAL HEALTH dPfCIALIST DATE
DCHD 10/9S
,.. .fie 1r .. .-�y r_„�;.. r .5, _ f. ,. !" ? e _ - �. .. .) „ rs.r ' ,.y—S yf,..3.:�}.. .-L . ._,,. ..x... ,.. ... i-..,r j'::r .., 1•_.e ,.,i .,, s..
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
` APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER ?&
ADDRESS ���7 �/�lI' A'4X _5'dxJ Zr SUBDIVISION NAME
"UJB C LOT#
DIRECTIONS TO SITE �7
DATE SYSTEM INST��A)JLLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY e549 10' NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Z/,�/l SPECIFY PROBLEM OCCURRING
DATE REQUESTED 'G INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93