864 Pine Ridge Rd .a3 ':89t.,.0 nd '.,`i:w`� .: �a'r.,. 'i''!'44f V "'."11.• t.j`. �'..4' .. d„ .aJ -.v k.. - .-t .: -, ,... . - ` •:-,-. _t, _
DAVIE COUNTY HEALTH DEPARTMENT
- - IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** This improyement 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)
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NAME O .D 5�� e PROPERTY ADDRESST 1'�e e►c�aQ � DATE C
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE l lob # BEDROOMS 3 t BATHS # OCCUPANTS GARBAGE DISPOSAL: YesJo
COMMERCIAL. SPECIFICATION: FACILITY TYPE`' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE,WATER SUPPLY � . DESIGN WASTEWATER FLOW (GPD) 2,9 d NEW SITE. REPAIR SWE
SYSTEM SPECIFICATIONS: TANK SIIE 0()1)GAL. `PUMP-TANK GAIL. TRENCH WIDTH 13 ROCK DEPTH I Sr+ +LINEAR FT. 0
OTHER.
a ,t
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS UR THE INTENDED USE-CHANGE. YOUR WASTERWATER'SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
14 .
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IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THEJ)AVIE 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 w.
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AUTHORIZATION NO. C � 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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DAVIE COUNTY HEALTH DEPARTMENT
If � IMPROVEMENT PERMIT and OPERATION PERMIT
`IMPROVPW-PERMIT "
'*4NOTE4* 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 C� . S ��`? �'� PROPERTY ADDRESS i t +'= c,n DATE
LOCATION L,C� \ a Y., l�\'ca
�wS C-."� •�.-.a�..�: `''tom a1.x'4h,..``^S.sJs�r.�a�s`� ., .. ....
SUBDIVISION NAME (� LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE oy` ' # BEDROOMS # BATHS 1 # OCCUPANTS GARBAGE DISPOSAL: Yes'N�)
COMMERCIAL SPECIFICATION: FACILITY TYPE ' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE I �.�. TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) .> O NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TAM( SIZE/66a GAL. PUMP TANK GAL. TRENCH WIDTH ✓� ROCK DEPTH J Sf LINEAR FT. _fir Ct U
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
k
.***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR KJST
-SEE THIS PERMIT BEFORE INSTALLING THE'SYSTEM. �..
L-- LL
IMPROVEMENT PERMIT BY '='s�=`
f
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:N-1:30 P.M. ON THE DAY OF INSTALLATION.,., TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
v
/DDS
AUTHORIZATION NO. O �� L{ DPERATIOV± RMIT BY +r, DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE IT IHE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE7TH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN NO WAY BE TAKEN
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR-MY GIVEN PERIOD OF TIME. }
DCHD 10/95
Davie County Health Department
y ti ENVIRONMENTAL HEALTH SECTION
P.O. Box 665 \
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 13OA, Wastewater Systems)
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental-!Health Section prior to,
issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie Co unty'Building-Inspections
Office when applying for Building Permits.**{
NAME d • � . S�1R DATE N2 029A
AUTHORIZATION N.M,9ER
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION • \6 s e
COMhENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM 4
**WIM**# THIS,AUTHORIZATION FOR.WASTEWATER SYSTEM CONSTRUCTION IS VALID FO((R`} A PERIOD OF FIVE (5) YEARS.
ENVIRON MENTA. HEALTH'SPECIALIST DATE
w
DCHD .10/95 v '
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME O • S A sa PHONE NUMBER 4 4 3 0 3
ADDRESS Q • 4 • 3 $�y P�N Q �Q� UBDIVISION NAME
C c�G LOT #
DIRECTIONS TO SITE d S - 1`1 Q
t—
DATE SYSTEM INSTALLED �1 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY \A d ry NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY W SPECIFY PROBLEM OCCURRING
DATE REQUESTED a�' - INFORMATION TAKEN BY4\
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.
u
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193