833 Calahaln Rd (2) I "
DAVIE COUNTY HEALTH 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 mast be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit. ,
(In compliance with Article 11 of G.S. Chapter 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME 'rca a '�\\� �V 4�'� Q `� PROPERTY ADDRESS 6k' 'l41Z11%- 9J - DATE I• �-9S
LOCATION W " t` A` A i�A N - I In► Q o N R► S 1 9 N J),
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION tFkIA-,TYPE, # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yea/,No
LOT SIZE WkR SUPPLY QCj,U uk v DESIGN WASTEWATER FLOW (GPD) 0 NEW SITE REPAIR,SITE
SYSTEM SPECIFICATIONS: TANK SIZE/b00 GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH /Q LINEAR FT. .3.00
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE,PLANS OR THE INTENDED USE CHANGE. YgJR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM: tFj
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' IMPROfMENT PERMIT BY �
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTXyFEALTH DEPARTMENT FOR FILL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:M-1:30 P.M. ON THE DAY OF INSTALLATION.- TELEPHONE.# IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY DAN r��I IA7l'►%4(teH;)-
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AUTHORIZATION NO. 605,2- 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 13OA, 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 10/95
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DAVIE COUNTY HEALTH DEPARTMENT _ -
< - � IMPROVEMENT PERMIT and OPERATION PERMIT
a ,
F :IMPROVF?IENT PERMIT
*+�N07�+E+� 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.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME 1 �+ = Ya .� ca� PROPERTY ADDRESS t• ' 'aha- DATE
. LOCATION �a W ` c r` A, Q �� � _ p1: d r� ��: � S i 4 to
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE U5 # BEDROOMS
# BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION.F'ACILITY'TYPE'w. # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/.No
LOT SIZE TYPE WATER SUPPLY Qcj
u ,"tv DESIGN WASTEWATER FLOW (GPD) 3 0 NEW SITE REPAIR SITE !/
SYSTEM SPECIFICATIONS: TANK SIZEL000 GAC:-•: PUMP TANK GAL. TRENCH WIDTH "`' ROCK DEPTH /Q LINEAR FT. 3 00
OTHER r
REQUIRED SITE MODIFICATIONS/CONDITIONS:
NNIS PERMIT IS SUBJECT TO REVOCATION IF SITE,PLANS OR THE INTENDED USE CHAFE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
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IMPROyEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY, HEALTH DEPARTMENT FOR FILL 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 INSTALLED BY DAN W�;. It YR;R
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AUTHORIZATION N0. 605-2- OPERATION PERMIT BY DATE 4
WHE 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 10/95
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Davie County Health Department
ENVIRONMENTAL.HEALTH SECTION
S P.D. Box 665 r
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(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.***
l M _ q�` AUTHDRIZATION NUMBER
NAME l�N% a.` DATE 11 "I h=' ® } ?
MANE ON IMPROVEMENT PERMIT (If different than above)
\\
SITE LOCATION P\ A�A'N �b IN
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWRTER SYSTEM �S w . o J��1 n`f�<<cc•.
**MICE THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION I5 VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST` : . . DATE.,
M DCHD 10/95 r
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Lorry '}.°��t� w\V w- DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
ab'J, 4%,% APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
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NAME L•ArrU Y1^f-bniv a La �� Fn-ToacQ ry%cbg,.,U PHONE NUMBER
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ADDRESS 2 0 W H v�uck,07&t PeQ SUBDIVISION NAME
IM 0CX4 U-01 t. V1 (_ ?,10 Z F( LOT#
DIRECTIONS TO SITE 4 w - Ca 1.ka_ VA o-.,e a,— i0- - 6" Fn,
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS -a NUMBER PEOPLE SERVED 2-
TYPE WA TER SUPPLY SPECIFY PROBLEM OCCURRING rr_DIaG`•., lQ r •�
4"11r S eA v---P 46Lt. 4e
DATE REQUESTED 1'a -31 -SIS- 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 r onsible for all harges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENTV��e��
Rev.1/93