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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMIT$ �oPROPERTY INFORMATION
Permittees
Name: C tTr 1—,� Subdivision Name:
Directions to property: Section: Lot:
IMPROVEMENT
PERMIT
' Tax Office PIN:#
w t Road NamedN _} ,�,±c?,X Zip:X7 061,
**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
constnlctior mstallation 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)
^• m ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER " .1
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPA N�#BEDROOMS � #BATHS�_#OCCUPANTS.GARBAGE DISPOSAL:Yes Sr N9�
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) 1� _ NEW SITE REPAIR SITE +'
SYSTEM SPECIFICATIONS: TANK SIZE Obd GAL. PUMP TANK GAL. TRENCIi WIDTH �•,ROCK DEPTH"Al� LINEAR FT. fitI
OTHER �
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
!-, ^`�°�"""+...,.V�.-.,,�,,,.,,,,''fir-...,�....� ��"'S� �..T�'�'•
71`
4
.Y. ,
**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: eV 113 \ \'A DM
LC)
4.G, �(\�
AUTHORIZATION N`4 OPERATION OPERATION PERMTf BY: DATE: 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 05/96(Revised) ,