382 Davie Academy Rd prJ••AF:f.7 yF•.-t ;...4,ad�.n•.'}"dS 'T>1%M1 y. t„i.e. .,;t-:;:. i• �.. :T, _
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�. aT DAVIE COUNTY HEALTH DEPARTMENT
-- IMPROVEMEM 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME o \S 1 5 PROPERTY ADDRESS 3�b Pv �C P�Q K.y R� DATE -10' 1 G
LOCATION Q svA�.— �� b'^ � ` '�A
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE Ov s Q # BEDROOMS # BATHS # OCCUPANTS __ ,_ GARBAGE DISPOSAL: Yes/No
COMMERCIAL. SPECIFICATION: FACILITY TYPE` # PEOPLE # PEOPLE/SHIFT # SEATS ,- 1-1 INDUSTRIAL WASTE: Yes`No
LOT SIZE � na TYPE,WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) yQ. MEN SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE GAL PUMP TAW GAL. TRENCH WIDTH yROCK DEPTH Q LINEAR.FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:°.
***THIS PERMI qS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. SOUR WASTERWATER SYSTEM CONTRACTOR IMUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM,
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IMPROVEMENT PERMIT BY 1 ,
**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
C ,
AUTHORIZATION N0. 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.
DOHD 10/95
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT F
AkOVEME d-PERMIT +
4.
**NO.TEk-T.hiv-improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
s system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the -
construction/installation
he`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)
_ _a7oa _
NAME � o C.1 S � t .y ��1 PROPERTY`ADDRESS 3% Bk\,,v,V, DATE
e
LOCATION � :-". .�.�. � � ��� �� 01 �..r�-a-�� � �1>c.��� C',c F,�. _L� _��. V,.
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS r) GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS .INDUSTRIAL WASTE: Yes/No
LOT SIIE r. TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) `id` NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE o GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH) Q0
LINEAR FT.
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. `
F _
Ho �,�..
h;.
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
1�
(Z
AUTHORIZATION NO. 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 GIP, PERIOD OF TIME. I
DCHD 10/195...
..4 t..� 5 .rr1.i s4 .�. :,.- ��' .,:.i..:+k'.r4.a::�ya�.. -Y...v Jr:..i 'aft . .b4 ,S` �y• . ) :.�� 5 •�.-- . ........' r.9. ' .' -'j r
Davie County Health Department _
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665 �s
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 oust be issued by the Davie County Environmental Health Section prior to
issuance of any Building Permits. This Foro/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.*** i
b R 1 e
AUTHORIZATION NUMBER.
\� "�O
NAME S S DATE " �/L No j 1 6 3
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
CONKNTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*HNDTICE*ff THIS AUTHORIZATION,.FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST. DATE
DCHD 10/95
' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION C�fJ LL � �
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) /��OGt) Gclf
NAME Ao b S PHONE NUMBER
ADDRESS :3$o� SUBDIVISION NAME-----
LOT#
AMELOT# ^
DIRECTIONS TO SITE �' lSo C�1'�-P ��. LE. o�J &F-ELO ���ip •
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER LS- OR ICI dA�- OWE
TYPE FACILITY kO U.S e— NUMBER BEDROOMS - NUMBER PEOPLE SERVED 2-
TYPE WATER SUPPLY C-a SPECIFY PROBLEM OCCURRING I a I —
DATE REQUESTED INFORMATION TAKEN BY /N ��- r
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
0
Rev.1/93