146 Pine Ridge Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
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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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME c,\o 6�.CsL PROPERTY ADDRESS T1-n e- )Z I J�&6— '10a DATE
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATA-.,,BUILDING TYPE # BEDROOMS tl # BATHS # OCCUPANTS L4 GARBAGE DISPOSAL: YeQ
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COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) "NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZEL62 GAL.� PUMP TAW GAL. TRENCH WIDTH 3' ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATION SPOITIONS:
***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 HEALTWTEPARTMENT,-FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1-.00-I:30 P.M. ON THE DAY OF INSTINION. TELEPHONE # IS (704) 634-8760.
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OPERATION PERMIT SYSTEM INSTALLED BY
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AUTHORIZATION No. 337S 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 B.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 .
DAVIE COUNTY HEALTH DEPARTMENT tU
IMPROVEMENT-PERMIT and OPERATION PERMIT
IMPi UO QENT 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)
NAME PROPERTY ADDRESS "-P!r '10a epATE
DATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
/
RESIDENTAL SPECIFICATION': BUILDING TYPE # BEDROOMS �_) # BATHS I # OCCUPANTS J4 GARBAGE DISPOSAL: YeQ
(COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY, DESIGN WASTEWATER FLOW (GPD) NEW SITE yREPAIR SITEy
SYSTEM,SPECIFICATIONS: TANK SIZE, 2GAL.' PUMP TANK GAL. TRENCH WIDTH 3ROCK DEPTH 1_ LINEAR FT. � �r
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.
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IMPROVEMENT PERMIT BY ,; C
**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
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AUTHORIZATION N0. 3 3 oPERATI0M1 PERMIT BYE �' DATE - I
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEK'DESCRIBED ABOVE HAS BEENJNSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BItj`SHALL IN NO WAY BE TAKEN AS A;
GUARANTEE THAT THE SYSTEM WILL FlUNCTION SATISFACTORILY FOR ANY GIVEN`PERIOD OF-JIME.
DCHD 10195-. �� ;
DavieCountyHealth Departsent
EMIRONMENTAL HEALTH SECTION
t. P.O. Box 665
Mocksville, N.C. 27028 �.Da
AUTHORIZATION FOR WASTEWATER SYSTEM,CONSTRUCTION
(Issued in coepliance with Article 11 of
G.S. Chapter 13OA, Wastewater Systess)
.***This Authorization For Wastewater Systet Construction Bust be issued by the Davie County Environsental Health Section prior to
issuance of any Building Persits. This Fore/Authorization Nusber should be presented to the Davie County Buijding Inspections
Office when applying for Building Pereits.+**
NATE Q A SZ. DATE �rj ` 9 b �AUTHDRIZAT0OI Ii
MR
ON IMPROVEMENT PERMIT (If different than above)
:SITE LOCATION N cL A6 4 A�.
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
\\' ENVIRONMENTAL HEALTH:SPECIALIST ':: DATE/L^
DCHD 10/95
1p DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
• APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �0 be R A�Q PHONE NUMBER
ADDRESS SUBDIVISION NAME
LOT\#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY OUSJZ, NUMBER BEDROOMS 2 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING .
DATE REQUESTED �° 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
Rev.1193