392 Junction Rd s� a,,:,:;u .a, w::yc.y♦ '+;:i"'W "` ':.(�,.. , ..�.., .,-:; .�•y'}i � ., W i. x,. .C - ,. + , - r _ .._-,1" ,.._1...
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
systema 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. ChhApter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME , PROPERTY ADDRESS
LOCATION
SUBDIVISION NAME IOiIV�G[�tL ��r.CLS LOT NUMBER T SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE l Se # BEDROOMS "—"/ # BATHS # OCCUPANTS —�K 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 i7
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TAME( GAL. TRENCH WIDTH r�ROCK DEPTH `? LINEAR FT. /S �
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
to#THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. _
lI
r
IMPROVEMENT 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 INSTALLED BY
+
i
441—
AUTHORIZATION NO. '! 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 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
Davie County Health Department
w ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
w" _ Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of k.
G.S. Chapter 130A, Wastewater Systems)
1
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to
issuance o?`iny Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building P mits.**#
AUTHORIZATION NUP'BER
NAME f �� DATEr /` �4 O 02
NAME ON IMPROVEMENT PERMIT II different than above)
SITE LOCATION ! • Il
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*ffNOTICE*H THIS AUTHORIZATIO R STEWATER Y5 CONSTRUCTION IS VALI FOR A PERIOD OF FIVE (5) YEARS.
ENUI AL HEALTH MECTAI IST DATE _: ,
DCHD 10/95 '
V, DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** Th is '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 PROPERTY ADDRESS �N 7�h ►// � 711a`XTE
LOCATION j&/I ( �r•?� �� �.
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
{
RESIDENTAL SPECIFICATION: BUILDING TYPE L1.s`� # BEDROOMS # BATHS _ # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIIE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) ! NEW SITE '' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE GAL. PUMP TANK GAL. TRENCH WIDTH �' . ROCK DEPTH LINEAR FT. S L'
OTHER
• REQUIRED SITE MODIFICATIONS/CONDITIONS: /•. ' _'
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING,THE SYSTEM.
i
IMPROVEMENT 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.
G �f
OPERATION PERMIT SYSTEM INSTALLED BY ,/•,Gc�+, '���.
AUTHORIZATION NO. OPERATION PERMIT BY /C v 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 130A, SECTION .1900 -SEWAGE TREATMENT AND DISPOSAL SYSTEMS-, BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTIONSATISFACTORILY-FOR ANY GIVEN PERIOD OF TIME.
DCHD .1O/95
�
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME eh elf PHONE NUMBER
ADDRESS u_)te-h�— a- - SUBDIVISION NAME71 :S JJ a--�--
vi✓ 0 �
LOT#
DIRECTIONS TO SITE 0 7'-'
DATE SYSTEM INSTALLED NA E SYSTEM INSTALLED UNDER P-
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED 7"_/l0 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 lication
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93 ����