273 Feezor Rd (2) .f
~�' + DAVIE COMITY 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 A �\\Pio hr,O So P PROPERTY ADDRESS $ o y DDE 1, 1
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION:'BUILDING TYPE o U3 # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes No
COMMERCIAL'SPECIFICATION:`P,06ILITY TYPE # PEOPLE # PEOPLE/SHIFT #,SEATS INDUSTRIAL WASTE: Yes/No
LOT SIIE TYPE WATER SUPPLY \-\)3n DESIGN WASTEWATER FLOW (GPD), `�D FEW SITE" REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL.`: PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER "
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PIANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
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IMPROVEMENT PERMIT V
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNT',HEALTH DEPARTM W,:FOR FINAL INSPECTIO(e# THIS SYSTEM BETWEEN
8:30-9:30 A.A. OR 1:00-1:30 P.M. pN fHE`DAY.OF, INSTALLATION.'7JELEPHONE # IS (7041'634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
V
AUTHORIZATION NO. OPERATION PERMIT BY DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMIPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWS TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
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DAVIE COUNTY HEALTH DEPARTMENT ,.
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
' **NOTE*f 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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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NAME G� C«1�\ N��-�Vu S,c 0 PROPERTY ADDRESS �� a -+� '�. F, � a DATE-
LOCATION 5 �Z N
SUBDIVISION NAME LOT NUMBER SEC./BLOC( NUMBER
RESIDENTAL SPECIFICATION: •BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #.SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY `'* `r DESIGN WASTEWATER FLOW (GPD)r��.� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE GAL. PUMP TANK 6AL. TRENCH WIDTH 1 ROCK DEPTH LINEAR FT. h5, 0
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.
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IMPROVEMENT PERMITD V
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMFOR FILL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:M-1:30 P.M. ON THE DAY OF INSTALLATION:'.TELEPHONE # IS 704Y 634-8760.
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OPERATION PERMIT SYSTEM INSTALLED BY'� L
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AUTHORIZATION NO. 7 OPERATION PERMIT.BY = '`r� DATE
**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 .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
Davie County Health Department j
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028 �.,�o. 013
AUTHORIZATION FOR MEWATER SYSTEM CONSTRUCTION
(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 Healthi.$ection prior to
issuance of any Building Permits. This Forn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.***
AUTHORIZATION NUVAR
NAlE A 'CM%A '(g - 7\�\o t- ,!�S o N DATE � "' 7 " � 027 ),
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION -Q. cl R oto
'`. COMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
.. 1.
*#*NOTICES THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS gAL�D FDS A1PF,RIOD DF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE
DCHD 10/95
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01 �� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �
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�'/Dj APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
ME PHONE NUMBER
ADDRESS_ oSJ 3 ����d i` /�C� SUBDIVISION NAME
A10, O LOT#
DIRECTIONS TO SITE
SS TJ m- OJ? ll -� D GIST 7 Irl
DATE SY TEM (IN AL ED Mo Q NAME SYSTEM ASTALLED UNDER V//'�
TYPE FACILITY 0 U_S NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �� SPECIFY PROBLEM OCCURRING
DATE REQUESTED ! '9� 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 -�` iI ✓ �
Rev.1193