2286 Hwy 601Sf
IMPROVEMENT PERMIT
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION 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 oust 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 IRA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS
LOCATION < Y1
SUBDIVISION NAME— "�"b` LOT NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP iANK GAL. TRENCH WIDTH _
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
DATE
SEC./BLDCK NUMBER
# OCCUPANTS GARBAGE DISPOSAL: Yes/No
# SEATS INDUSTRIAL WASTE: Yes/No
NEW SITE REPAIR SITE
ROCK DEPTH LINEAR FT.
***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.
� I
t—
r1
� I �
YF
y• �
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
AUTHORIZATION NO. Ci ' K "
SYSTEM INSTALLED BY
OPERATION PERMIT BY DATE /G
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIAtCE WITH
ARTICLE 11 OF G.S. CHAPTER IRA, 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.
I I
i
DCHD 10/95
a
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
--� APPLICATIeON_ FOR IMPROVEMENT PERMIT (REPAIR)
NAME �:v .��J73�y PHONE NUMBER
ADDRESS IO y` v 4 I S
�{1c� SUBDIVISION NAME
13z \ LOT #
DIRECTIONS TO SITE C� U I S _ 1\\ - '�'�- A�VV C.'_4A
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 64--� NUMBER EEDROOMS f� NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED J�_ 1 T INFORMATION TAKEN BY �- • 1 V
This is to certify that the information provided is correct to the best of my knowledge, and that I understand 1 am responsible for all charges incurred from this application.
�4. /• A r _
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION �� , 0 b
P.O. Box 665
Mocksville, N.C. 27028 Q�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION C
(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 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.***
AUTWARIZATION NLY..9ER
\
NAME �� d O `(, @ y DATE
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COM1ENiS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICES THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE
DCHD 10/95