197 Casa Bella Drive Lot 5"� s •.l:r DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT e
IMPROVEMENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIIATION 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 .1980 Sewage Treatment and Disposal Systems)
D
NAME ca Q PROPERTY ADDRESS L% ? `P 3 �QLI �� Rr DATE
LOCATION h s3� CS,
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANT5 �GARBA6E DISPOSAL: Ye/No
COMMERCIAL SPECIFICATION: FACILITY TYPE A. # PEKE # PEOPLE/SHIFT #,SEATS, INDUSTRIAL WASTE: Yis/Nom
LOT SIZE Ob .; WATER SUPPLY' Sg_ DESIGN WASTEWATER FLOW AGPD) 3 C -,a NEW SITE REPAIR SITE
SYSTEM 5PECIFICATIDNS. TANK SIZE 1000 GAL. PUMP TANK GAL. TRENCH WIDTH`_ ROCK DEPTH LINEAR FT. Iy
1 a
OTHER. z
� a
REDUIRED 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.
1 '
HCONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTIENT.FOR FINAL., INSPECTION OFTHIS SYSTEM BETWEEN
8:38-9:30 A.M. OR 1:WI :30 P.M. ON THE DAY OF INSTALLATION TELEPHONE # IS '(704) 634-8768.
OPERATION PERMIT
AUTHORIZATION NO. O 1J
OPERATION PERMIT BY DATE 9-7— 1G
**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 .1980 'SEWAGE TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOPILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
DAVIE COMITY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IIROVEMENT 'PERMIT r
- **MOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank smelt Ony wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME N h14 PROPERTY ADDRESS .9 7 `I+s t•`4' �` R DATE
LOCATION l LA ` on
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS 4b-'GARBABE DISPOSAL: Yee
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE t 06 1 ti' TYPE° WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE -
SYSTEM SPECIFICATIONS: TANK SIIE )QOD GAL. PUMP TANK GAL. TRENCH WIDTH "ROCK DEPTH LINEAR FT. 11J c)
b
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
t
***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. •-
4
F
IMPROVEMENT PERMIT BY ��'?.a�— s, .� �•1r�
**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.
�S
r� }
/ J
OPERATION PERMIT SYSTEM INSTALLED BY
sd,
AUTHORIZATION NO. O OPEk) IOW PERMIT BY DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED AAE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 13OA, SECTION .1908 "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
e
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
(� APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) G
NAME 0 PHONE NUMBER �C 1
ADDRESS '� ' b X SUBDIVISION NAME \1k) Oo
�\e' �'P�e �� �.. .�VO LOT#
DIRECTIONS TO SITE d (z,"
ck
DATE SYSTEM INSTALLED `C) NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED tom" 1 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
��V
DavieCountyHealth Department -
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
V1d/ O d
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
t3
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction oust be issued by the Davie County Environmental tHealth 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.*** f `
NAME 1 o U O -S DATE I
AU UTHDRIIAT0D 3N 3
NAME ON IMPOPENT PERMIT
SITE LOCATION AS
11
(If different than above)
COMMENTS/CONDITIONS ON AUTHORIIATION TO CONSTRUCT WASTEWATER SYSTEM