113 Alamosa Drive Lot 8j DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
r.Permitt6e's
iy; ,tetto f.c. I Subdivision Name ''1-. V ?t i e a `I"
D1�rections to property: ta.�lc . 4,'Section: 1 Lot: £�
IMPROVEMENT
PERMIT Tax Office PIN:#
{ 5.?�l,\{1rw r!1 ~{ ►'.'rn. L t to t,tt,yrt<!"4.t� �� +') x � L EA "•.at_' ROad^Name:A'L- zip. L.-Jc('�
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTALHEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
i r INSTALLING THE SYSTEM:
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS Z-) # BATHS 2 # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY, TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
TYPE WATER SUPPL �+ DESIGN WASTEWATER FLOW (GPD) NEWS {
LOT SIZEt�xI Sd Y�-Uy^��� ITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH =t' ROCK DEPTH � LINEAR FT.
OTHER , � 1 ST Q l F::' t) 110.J ? is
REQUIRED SITE MODIFICATIONS/CONDITIONS: t �S�A �-l- C) I) Cz -Tot) �` j �l 1:J) 1;2 � ��v �. t �':, � , V I via --T SJeJjlr
W4 7C
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER* *RISER(S) IF 6'l BELOW FINISHED GRADE*
�voo a�ti � Q
"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) 0 -VW X X X X
(336)751-8761
OPERATION PERMIT
SYSTEM INSTALLED BY:
ODD
t,
ql,d
4L L0.
Ll
AUTHORIZATION NO. j� OPERATION PERMIT BY: / DATE: vCJ
"THE ISSUANCE OF. THIS OPERATION PERMIT SHALL INDICATET T SYS DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION. 1900 "SEWAGE TREA ND 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)
a ',.�` ?� -t `- ' •. a s' _',>d+ v y r yY' i.,, 3..::.Si s
`a.� } .+t rf .';7., i' ...q,.+. ,,. ``d �' q ° : : r1k
Ar
' DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
W Permittee's" A
d
Name: t i i1._:t D Subdivision Name:
Directions to property: 'fit ! T ;" °-''. Section: i Lot:
IMPROVEMENT
•,; ,, , s
PERMIT
Tax Office PIN:# -
4 .. •, , iRoad Name , , t,M Zip,
**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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE4AkA-- # BEDROOMS= ` # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFP # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZII L x �'� TYPE WATER SUPPLY LL- t- Ji `e DESIGN WASTEWATER FLOW (GPDZ (1"C1 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH :" ROCK DEPTH � � LINEAR FT. 'r
OTHER
hJ - f �' �, t �r.. • ,� roc
REQUIRED SITE MODIFICATIONS/CONDITIONS: � fi� .-'.�� �.-�.. C.`!J � c• l Loci �'' � l:.l:.� � i,;. C';1 � � 1 c . i...� � =� , '`'`�, j
i
boA -n:- .
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER' *RISER(S) IF 61-1 BELCH FINIMCED GRADE*
11
"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) 63' -
xxxxx
(336)i5t-87
OPERATION PERMIT
SYSTEM INSTALLED BY: `
AUTHORIZATION NO.OPERATION PERMIT BY: / . /'l _ DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE SYS DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11'OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREAT D 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) ,
IT
1
1v
ti
"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) 63' -
xxxxx
(336)i5t-87
OPERATION PERMIT
SYSTEM INSTALLED BY: `
AUTHORIZATION NO.OPERATION PERMIT BY: / . /'l _ DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE SYS DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11'OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREAT D 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) ,
67
LK .
118
68
119
69
120
o loo 100
.A OUINTA
1 50.23 151.75
46 0
6 0 -A 7
70 71 72
LA QUI NTA "B _
S EC. I —
121 122 123 0
P84- 125
00 100 100
DR.
155.24
20$R W 6 19 CA
0
1 5 0
N
45
,A
1 51.5 2 21
U1
cn
1 5504. 18
5
o
D
8 ��
��,
5
D
,A QUINTA
7
-
O
SEC. i
44
22
�
17
v
4
0
c,z
9
rn
4
o
—
P. B. 4, 125
rn
_
m
—
LA
QUINTA 16
v
3
43�,
v
3
0
10
SEC. 1
4
24
15
2
42 0
1 1 11 11
A
P. B. 4- 125
25
155.04 ( 4
I
41 0
12 _
�
c�
I
U
o
cD
co
150
155.07
2 6
13
O S
D R.
—
0
13
0
25
0
0
150
151.52
7
40
1 55.23 12
o
014
4
24
cn
1 49.3139
0
—
150.29
j 55 66
6
II
o
=
28
Q
0
• .i
73 7 4
w
1� � 125 A
CP �� �
104 .86 115.30
I
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME �' G� e 9a /-S PHONE NUMBER
ADDRESS IISA/14114r4 �� SUBDIVISION NAME �pu�li4 `ham
�0vlrncc G.27oo sem"'O-
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 17' NUMBER BEDROOMS _�3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED L/' L%oy INFORMATION TAKEN BYy SCJ
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. 1/93
PSN��-oa�9 ft�f o a-) ,,4:40+ �3 �j