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301 Granada Drive Lots 91-93, IDAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTYINFORMATION Penfiittee' r `� ^Name:., Subdivision Name: �rjt r� f'VA Directions topipperty: Section: Lot: '' L IMPROVEMENT. PERMIT - Tax Office PIN:# , Road Name kzip: **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 priorto the construction/installation of a system or the issuance of a building permit. (In compliance with Atticle I 1 o G.S. Chapter 1130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) Nq***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIR0 MENTAL EALTH PECIAT ST. DAD SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE L INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS -.,I— # OCCUPANTS GARBAGE ARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No ti/A:� LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. —00 OTHER " REQUIRED SITE MODIFICATIONS/CONDITIONS: "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 (MMt V (336)751-8761D OPERATION PERMIT - `' lJ �L..t��0� SYSTEM INSTALLED BY: �. LID Ag �1lb ,R { CJS . �^ t1 �� uL �10� Ft•� i:� Ar INS.Pat itO� -1 CST Sp' COMPU:'tLs D AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE TPAT THES M ESCRIBED ABO AS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT DISPOSAL SYS S", 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) • ` . APPUCATION F011 SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Q . - En vftnmenta/ Hgwith Settfon • P.O. Box 848/210 Hospital Street Mockaville, NC 27028 (336)751-8760 AUG 2 3 2(}01 ' ENVEROP�MVE JAL HEALTH AI I. T ***XHPCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UWXS$ HIZ--REQ1hRI6'; IMRMATION IS PROVIDED. Refer to the INIrORMATION BULLETIN for instructions. 1. Rasa to be Killed S Contact Parson G Nailing AddressH D� //�/ aom * who" — City/stat./EIP i/G4 ryee, /l(,_ 704 6 business Phone 2. Nese on Permit/ATC it Different than Above Nailing Address City/state/sip 3. Applioation Tor: ❑ Site ]Evaluaion B'I�mprovement Psrmit/ATC ❑ Both 4. system to services ❑ House 2 -'Mobile Home ❑ Business ❑ Industry ❑ Other �•I••; 5. If Residence: I People I Bedrooms I Bathrooms _/ � a Dishwasher Garbage Disposal thing Machine 0 Kassmant/Plumbing ❑ Kassmant/No Plumbing 6. if business/industry/others Specify type I People I Sinks I Commodes I Showers I Urinals I Nater Coolers IF iwDSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of Nater supply: runty/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is Intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: /%Z%� 0 - ;7-� Re--Jz--J-�YWRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # F ,�e�'7 ��fy�d�,c� ,r Property Address: Road Name O/ el"alvAJt4 hk- City/Zip 14ryc?2. /JI G, dcc�iT�O LrUt� Y� t r` Aj 4aro r/'4 - If in a Subdivision provide- Information, as follows: Fra 'T Name: D A, n,,V4 i' Section:_ Block: Lot: � o9- Date Property Flagged: This Is to certify that the Information provided Is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, If the site plans or Intended vee change, or If the information submitted in this application Is falsifled or changed. I, also, understand that I am responsible for all charges Incurred from this application. 1, hereby, give consent to the Authorized Representative of the Da ou Health Department to enter upon above described property located In Davie County, and owned by z to conduct all testing procedures as necessary to determine the s�te sultsb�lty. DATEa 043 ©� SIGMA' THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includd all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). I Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: I EIIS: Account No. Invoice No. )O�50