1323 Baltimore Rd v'X0
DAVIE'COUNTY HEALTH DEPARTMENT
a IMPROVEMENT PERMIT and OPERATION PERMIT r
IMPROVEMENT PERMIT
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**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater k
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 �/1LIr/,eS Ii�.j��,v 1- PROPERTY ADDRESS iDATE
LOCATION rf
SUBDIVISION NAME LDT�NLMBER SEC./BLOCK.NUMBER
RESIDENTAL SPECIFICATION: :BUILDING TYPE # BEDROOMS .S # BATHS t° # OCCUPANTS GARBAGE DISPOSAL: Yet Llg_�_
e 3 e.
COMMERCIAL. SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLElSHIFT SEATS iNDIISTRIAL,WASTE: Yes/No
LOT SIZE t� TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE L�
/�2'1 3a
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TRM6l 140 GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. r
OTHER
REQUIRED SITE hODIFICAT'i0N5/CONDITIONS: .f
,.
***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.
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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 1:0-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
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AUTHORIZATION NO. COQ OPERATION PERMIT BY IYX41 DATE I4�1
**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
r 4,+ DAVIE COUNTY HEALTH DEPARTMENT X
�-:-- IMPROVEMENT;PERMIT and OPERATION PERMIT
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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 CDNSTRUC ON must be obtained from this Department prior to the
construction/installation of a system or the issuance a building permit.
(In compliance with Article 11 of 6.5. Chapter 130A, Wastew er Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME �/JfI/'�S 1%�1.?�'t'�✓ S PROPERTY ADDRESS DATE A Z'
LOCATION J T ' :�r1f
SUBDIVISION NAME t`ti ""i`-LO_T_'NJMBER VSEC,/BLOCK,NUMBER
/• 5
RESIDENTAL SPECIFICATION: BUILDING TYPE �P' # BEDROOMS 3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PED ~/S WT SEATS,_''1 fiiVRYMhL,,WASTE: Yes/No
LOT SIZE /etc TYPE WATER SUPPLY 111f // DESI6N WASTEWATER FLOW (6PD) _5f NEW SITE REPAIR SITE
/•2
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TAM( Ct GAL. TRENCH WIDTH ..? ROCK DEPTH LINEAR FT, iV1
OTHER
REQUIRED SIiE.ZIODIICATI�15/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
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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 1704) 634-8760.
y �
---- _. __ _ SYSTEM"'INSTALLED BY
OPERATION PERMIT
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ger
AUTHORIZATION NO. 8D9k 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
61JARANTEE THAT THE SYSTEM-WILL FUNCTION SATISFACTORILY FOR ANY 6IVEN PERIOD OF TIME.
DCHD 10/95
Davie County Health Department
• ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C.' 27028
AUTHORIZATION FOR W 67MTER SYSTEM COISTRUCTIOI
(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 RIZATION NUMBER
NAME (, xl4r,/y /4rn srj 0117 S DATEr10 "= 9jN2 U U 918
MANE ON IMPROVENENNT PERMIT (If different than above)
SITE LOCATION ,'4V
CONTENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**MICE*** THIS AUTHORIZATION EOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONNENTALUALTH SPECIALIST DATE
DCHD 10/95
i
u DAVIE OUN NVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME Lhccr'k _9bPHONE NUMBER
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ADDRESS 1, � fi� �2d/'�- - SUBDIVISION NAME
1�
de, /Y � 7d� GJ LOT #
DIRECTIONS TO SITE _'5 e7tr
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DATE SYSTEM INSTALLED i'S NAME SYSTEM INSTALLED UNDER
TYPE FACILITY CIs� NUMBER BEDROOMS NUMBER PE PLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
J
DATE REQUESTED INFORMATION TAKEN BY a 0
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