225 Wing Haven Ln - _ A
1. _ , DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMEN 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 .19M Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS SCLC KB,,, 1V/ .2 70;2r DATE
LOCATION (.001 c. lkxtz'�'
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE 00.3Q # BEDROOMS 3 # BATHS # OCCUPANTS 3 GARBAGE DISPOSAL: Ye /No
COMMERCIAL.'SPECIFICATION: `FA)CILITY STYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes%No;.
LOT SIZE 1 0 d TYPE;WATER SUPPLY (tl Z!K DESIGN WASTEWATER FLOW (CPD) 0 NEW SITE y' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE doo GAL.. PUMP TANK GAL, TRENCH WIDTH ROCK DEPTH LINEAR FT.
s
OTHER N.",
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION,,IF SITE PLANS OR THE INTENDEDUSE:CHANGE: YOUR'VIASTERWATER SYSTEM CONTRACTOR MUG
SEE THIS PERMIT BEFORE-INSTALLING THE'SYSTEM.
wo
1(7
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 SYSTEW INSTALLED1 BY \� O V AJ
z
AUTHORIZATION NO. 5 OPERATION PERMLT,BY DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE NIRS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER INA, 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
...P.I-•Yy. ` } .'�'/ w. ._ - �. .:.�..._ .r.•.w.+>�.q,,,`-.+:f-;;� s�. t,.+•s.,tiT,✓r,. -,-;� /O
DAVIE CDUNTY HEALTH DEPARTMENT +,
IMPROVEMENT PERMIT and OPERATION PERMIT
' IMPROVEM f 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAMEc�Cr.. c` -2y-So iJ PROPERTY ADDRESS ,�/iCkzP 7a' e
tt DATE,.�-
LOCATION LO U
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS -�� # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye /No t
COMMERCIAL SPECIFICATION: FACILITY,TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE O+� TYPE WATER SUPPLY to A DESIGN WASTEWATER FLOW (GPD) 3 / U ' NEW SITE REPAIR SITET;:"�'
SYSTEM SPECIFICATIONS: TANK SIZE QOU GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. �~
OTHER '
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR-UASTERWATER SYSTEM CONTRACTOR MUST-'
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
14 t
r
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):634-8768.
OPERATION PERMIT SYSTEM'INSTALLED BY '�q'r-' `'``� }, 1'+ \l
r
t
AUTHORIZATION N0. Li 5 OPERATION PERMIT 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 FRICTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95 ' •
Davie CounTy'Health Department
ENVIRONMENTAL HEALTH SECTION LL
P.O. Box 665 ,
Mocksville, N.C. 27028 ' 9
AUTHORIZATION FOR WASTEWEMTER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater.Systems)
***This Authorization For Wastewater System Construction must be issued by the.Davie County Environmental Health Sectioti Iior 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.***
AUTHORIZATION NUY.RR
NAME ` c. �-� �1 t2 P. S o'1a DATE O —S 9 N2 0 4 5 3
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*HNOTICE*ff THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FORA PERIOD.OF FIVE (5) YEARS.
ENVIRONMENTAL"WATH SPECIALIST DATE
DCHD. 10/95 x
1 3a v. ._i .. ... .% i Y� i.. ... r.•- t ea v Y n vr..a e
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Q�h
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) q
NAME c� S o a PHONE NUMBER 9 I g -7 a-
22S runs �v�✓Lw•
ADDRESS SUBDIVISION NAME
ONe , N •� . D� b-2A LOT#
DIRECTIONS TO SITE
ov,
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY �� `R. NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Qo SPECIFY PROBLEM OCCURRING
DATE REQUESTED TS -5 - "It INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I u derstand I am esponsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT ~
Rev,IN