129 Little Rober Rd ' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT f
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 6.S. Chapter 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS r �-�t h► �Q �be 1�a DATE
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
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RESIDENTAL SPECIFICATION: BUILDING TYPE AM54 - i BEDROOMS t BATHS t OCCUPANTS J GARBAGE DISPOSAL.: Ye No
COMMERCIAL SPECIFICATION FACILITY TYPE # PEOPLE # PEOPLE/SHIFT, #`SEATS INDUSTRIAL WASTE: Yel/Nor
LOT SIZE •b JJ o�� TYPE WATER SUPPLY i) DESIGN WASTEWATER FLOW•(GPD) 3 6b NEW SITE "IR'SITE 1�-
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH : LINEAR FT. �
OTHER 1J - 4 X,: - 1"�}.!✓ i
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS 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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IMP VEMENT PERMIT BY
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**CONTACT'AA~REPRESENTATIVE OF THE DAVIE COUNTY ;TH•D€PAA S. 9 FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF'IN$�Al�,.toTITELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY � s �•�osvr �• �
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OPERATION PERMIT BY .
AUTHORIZATION NO. 37 5 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 TREA T AND DISPOSAL SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY IVEN PERIOD OF TIME.
DCHD 10/95
DAVIE COUNTY HEALTH DEPARTMENT '
}°`• " IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT,PERMIT
**NOTE** This improveeent permit DOES NOT authorize the construction or installation of a septic tank y tie 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 -�1 Ata4 DATE S - �
LOCATION :>rt, C- I-, t5�s-- TS + C� r. c���� �r�,' •�� a i..
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE �'�� -°- # BEDROOMS # BATHS # OCCUPANTS •a GARBAGE DISPOSAL.: Ye4/No)
COMMERCIAL SPECIFICATION: FACILITY TYPE ' # PEOPLE # PEOPLE/SHIFT #'SEATS INDUSTRIAL WASTE: Yes/No".
LOT SIZE •� 1> t�zs TYPE WATER SUPPLY y� DESIGN WASTEWATER FLOW (GPD) 366 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TAMC{ GAL: TRENCH WIDTH J :..;, ROCK DEPTH � LINEAR FT. z
OTHER- 0)C`". �- t j
REQUIRED SITE MODIFICATIONS/CONDITIONrS:
Y ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS.:OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THEASYSTEM. `"�"'� —•e
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IMP DEMENT PERMIT. BY
**CONTACT'd REPRESENTATIVE OF THE DAVIE COUNTY HE JH EPAR�TM NL �FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR f�-1:30 P.M..-ON THE DAY �I1�TIPHONE.# IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY •_�`��S»�+rs+�.,�sw lJ�.t.Se�N�
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AUTHORIZATION NO. OPERATIONIPERMI BY DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE,THAT SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAG TREA T AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOPILY FOR ANY IVEN PERIOD OF TIME.
DCHD' 10/95
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
11;
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(Issued icompliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Hearth 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.*** ti t
NAME O 4. S � DATE 5 �� �f L AUTHORIZATION NU 5
N2 0375
NAME ON IMPROVEMENT
#PERMIT
C(If different than above)
SITE LOCATION _ ! 2 l V� �Q �o�Q �c�. C�V +A N c 4 4 N �.�0 O �.
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NDTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRON ENTAL HEALTH SPECIALIST Y; DATE
DCHD 10/95
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Cf, fy CW6 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION y
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) p ,/-
NAME ✓)r J PHONE NUMBER
ADDRESSP_ /U - SUBDIVISION NAME
• flcL ya"CV. -- C r� co LOT#
DIRECTIONS TO SITE oL � cL ' . r�GZ.U1 Q.LC) j
DATE SYSTEM INSTALLED •NAME SYSTEM INSTALLED UNDER—
TYPE FACILITY NUMBERBEDROOMS NUMBER PEOPLE SERVED
���X�
TYPE WATER SUPPLY `
SPECIFY PROBLEM OCCURRINGvl,;ah
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DATEREQUESTED `7 / 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 �i.� Dri��1�j
Rev.1193