390 Beauchamp Rd r •.,...,: DAVIE COUNTY HEALTH DEPARTMENT
3' 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.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAIL VW � PROPERTY ADDRESS7yfIA7 ,D.' a 70 DATE
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LOCATION �' c* U` tbi t� "� .� Win► Q u G.t�,' �cr� -, jsn
SUBDIVISION NX LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE o' sQ # BEDROOMS 3' # BATHSD-9 # OCCUPANTS 6ARB( E DISP : Ye Na
COMMERCIAL SPECIFICATION: FACILITY T4,, # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTEL,�.eLNo
LOT SIZE S TYPE WATER";,%1PPLY DESIGN WASTEWATER FLOW (GPDj t 6FA3 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEI!!lDOD GAL. PUMP hNit""t GAL. TRENCH WIDTH ROCK DEPTH hNEAR FT •§
OTHER,.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE`70LAR OR THE INTENDED USE CHANGE. YOUR WAST,�RWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE`INSTALLING THE SYSTEM. r
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IMPROVEMENT PERMIT BY5
4
**CONTACT A REPRESENTATIVE OF THE DAVIE COMITY HEALTH DEPARTMENT FOR FINAL INSPECTION"'OF THIS SYSTEM BETNEEN _,..,.
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 b a 14 4'
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AUTHORIZATION NO. a��� 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
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jv' _ Davie County Health Department f I
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
-- _ Mocksville, N.C. 27029
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 Heitth Section prior to
issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County BE ld ng Inspections
Office when applying for Building Permits.***
��V .��, AUTHORIZATION MISER
NAME
•� P�� s DATE
MANE ON IMPROVEMENT PERMIT (If different than above)
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SITE LOCATION VI)
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**MICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
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ENVIRONENTAL HEALTH SPECIALIST DATE
- DCHD 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
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1. Application/Permit Requested �B(� r ,/�
Mailing Address C3` `� 3 Home Phone �O 3�-t ®'(J SCS �y
Ll-C yV - Business Phone 9.(0
2. Name on Permit if Different than Above
3. Application for: C3General Evaluation eptic Tank Installation Permit
4. System to Serve: 94use ❑ Mobile Home ❑ Place of Public Assembly f
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❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot # ;
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�Basement/Plumbing
No. of People ❑ Basement/No Plumbing f
No. of Bedrooms L�►ashing Machine
No. of Bathrooms J ishwasher
Dwelling Dimensions a -l S l` / Garbage Disposal
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6. If business, industry, place of public assembly, other: Specify type
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No. of People Served No. of Sinks
No. of Commodes No. of Urinals
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No. of Lavatories No. of Water Coolers
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No. of Showers Water Usage Figures ('
7. Type of water supply: ublic ❑ Private ❑ Community
8. Property Dimensions c.J Sewage Disposal Contractor }
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type? i
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'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
RPR f
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Directions to Property: Tax Office PIN #
/ � � � Road Name y
Box # (if available)
L 1 �A� ����. a _ City v
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This is to certify that the information provided is correct to the be of my owledge, and I understand I am responsible for all charges F
incurre rom this ap licati
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DATE SIGNATURE
CONSENT FOR SITE EV UATIO BE DONE ON ABOVE DESCRIBED PROPERTY
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MUST CHECK ONE: &D I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by.the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determi a said site's s ' bility for a ground absorption sewage treatment
and dis/p/Qsal system.
DATE SIGNATURE
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DCHD(1/93) a