166 La Quinta Drive Lot 1+'1 y.. i:� + i�";t a+- ;'� Z ... 1t +, it i Y ;.-.}v. ..`r`• ; . • + )+ •i; �� ..
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r DAVIE COUNTY HEALTH DEPARTMENT
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 G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME V A c� N Y 1 A 5 V cL PROPERTY ADDRESS l� �o h A Q .a� � � fz -DATE 4 -9
LOCATION l_
N
5UBDIVISION NAME It
SEC./BLOCK NUMBER
RESIDENTAL SPECIFICtTION: BUILDING TYPE 1.�Atte� # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICATION:`40LITY TYPE' "•> . # PEOPLE # PEOPLE/SHIFT `" # SEATSINDUSTRIAL WASTE: fifes/No
,t ..
LOT SIIE n t TYPE -WATER SUPPp DESIGN WASTEWATER F� W iGPD) hEW SITE!.! REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE PUMP TANK GAL. TRENCH WIDTH / ROOK DEPTH i� +LINEAR FT. X1400
OTHER 4.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMITS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTEND'E'D USE CHANIi�E. YOUR NASTERWATER'SYSTEM CONTRACTOR MUST c
SEE THIS PERMIT BEFORE INSTALLING THEItYSTEM. t r
P 1%P
IMPROVEMENT •PERMIT .BY�_s.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 IG,E'_ 2'1%e- 6,ed k /W Cr
------------
lbs'
F
n.
ry
AUTHORIZATION NO. D a 7 R OPERATION PERMIT BY
DATE 10 g fo
**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 136A, 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.
DOHD 10/95
,'..;s <�`
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
' IMPROVEMENT PERMIT
*ATE** 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,fro this Department prior to the
construction/installation of a system orFthe issuance of a building permit.
(In compliance with Article 11 of`G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
0 174 Ob
NAME �� F, ci toy , A ' Ali _ PROPERTY ADDRESS �r�� ►1 t\ .1.� xr•� t� vDATE t �o
LOCATION �n " 1 l; �-• �^c•t c'* .,h 1 .-,�r��(a `` c h' , ri �. P. C ,1 E, �Hc� L� s> i
SUBDIVISION NAME `7iV4Q�'� ✓0. t e l i"', LOT NUMBER r SEC. /BLOC( NUMBER
.RESIDENTAL SPECIFICATIT: BUILDI TYPE oma #BEDROOMS ,� #BATHS # OCCt ANT$, "'., GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICATION: �FACILIT # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: yes/No
LOT SIZE tj oc�� TYPE WATER SUPPLY DESIGN WASTEWATER FLOW'(GPD) liUIy
NEW SITE'. "REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE t0n�GAL. PUMP TANK GAL. TRENCH WIDTH ROCK,DEPTH I �L� LINEAR FT.
OTHER ! crt 4
REQUIRED SITE MODIFICATIONS/CONDITIONS:.
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHAgE'.' YOUR•WASTERWATER SYSTEM CONTRACTOR MUST ;
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ,. ►f> - y.
f........ v
IMPROVEMENT PERMIT/IBYJ ,` -i� r�a� ` •~4j,
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY`HEALTH DEPARTMENT FOR F14 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 l C k MAA e; 944p / W Cr
4v
AFU";
•
AUTHORIZATION 190. D OPERATION PERMIT BY DATE -
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE II.OF G.S. CHAPTER 138A, 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. .
�DGHD 10/95 '
.r
I,e
4
Davie County Health Department
t ' , ENVIRONMENTAL HEALTH SECTION
R�'
1 P.O. Box 665
6 0. 00
MocNsville, N.C. 27028
AUTHORIZATION FORWASTEWATER SYSTEM CON5TRUCTION
(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
County Building Inspections
Office when applying for Building Permits."*
'}
NAME la. N N �/ e P q Q DATE ���- ' 1 Cn
:..AUTHDRIZATION NUVAR
N° 0293
NAME ON IMPROVEMENT PERMIT (If different than above)
;•
I �j/1
706oc/Va e
t 1
SITE LOCATIDr!
COMMENTS/CONDITIONSj3N AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*#*NDTICE*ff THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
�.
ENUIRONMNTAL HEATHOPECIRAT,.oeDATE;..
,
DCHD 10/95
i DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME A N �k V PHONE NUMBER C1 5 - �-
ADDRESS (� b i� Q A�.�a.� R SUBDIVISION NAME OCIi/a e �
V p N c� 1 N LOT #
DIRECTIONS TO SITE �i _ I 1 ��
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY a'�' NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY � SPECIFY PROBLEM OCCURRING
DATE REQUESTED 3 / L INFORMATION TAKEN BY C •
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