335 Duard Reavis Rd Yo
Davie County,Health Department
ENVIRONMENTAL HEALTH SECTION ` ` ~�0• O
P.D. Box-665
Mocksville, N.C. 27028
AUMIZATION FOR WASTEWATER SYSTEM CONSTRUCTION ti >J
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Sys�ems)
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***This Authorization For Wastewater System Construction must be issued by Ae;,,Davie County Environmental Health Section prior to
issuance of any Building Permits. This�,ore/Authorization Number should be=p're'sented to the Davie County Building Inspections
Office when applying for Building Permits.*** (�
a e -S AUT_HORIZATIONNUMBER UMBER
NAME N 0177
MINE ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COM01TS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*** THIS`AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST . DATE
DCHD 10/95
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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)
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NAME 4P.P. eN N a R,.5 PROPERTY ADDRESS 5 '\ \\"nX ts%s 1A DATE 3_Q
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE s e # BEDROOMS # BATHS # OCCUPANTS 2 GARBAGE DISPOSAL: .Yeskj�
w�
COMMERCIAL SPECIFICATION: FACILITY TYPE "s r!# PEOPLE # PEOPLE/SHIFT' # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE U TYPE WATER SUPPLY. SL DESIGN WASTEWATER FLOW'(GPD) NEW SIE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE'" GAL: PUMP TANK GAL.. TRENCH WIDTH �. RDCK.'DEPTH LINEAR FT. SO ( .
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT1S SUBJECT TO REVOCATION IF SITE PLANS OR THE INENDED USE CHANE. YOUR WASTERWAER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. Fes.
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'
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 SYSTEM INSTALLED BY
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AUTHORIZATION NO. x,1`17` OPERATION PERMIT BY `� Cdr` DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICAE 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.
DCHD 10/95
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DAVIE COUNTX HEALTH DEPARTMENT
IMPROVEMENT PERMIT,aand 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)
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NAME 1.r�� L +:� a �`r. �� PROPERTY ADDRESS .�� �}yt�+z.� a i�`.�15 t\e DRTE
LOCATION ?J
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� �� ^r .>:. � ` ��`r►r. �J yr�r �,« _ •�" '�`�c� CJy�,�. `\ �rrA ti �G
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS 'fZ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes 61g
COMMERCIAL. SPECIFICATION: FACILITY TYPE "'# PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE U TYPE WATER SUPPLYV.Iu�4 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
"'SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH W LINEAR FT. /fo '
'
OTHER
REQUIRED 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.
H a -- {�
IMPROVEMENT PERMIT BY �.. -:'
{*CONTACT A REPRESENTATIVE OF•..THE DAVIE C011�TY HEALTH DEPARTMENT FOR FIM INSPECTION OF THIS SYSTEM BETWEEN
-8:30-9:30 A.M. OR 1:00-1:30 P.M. ,THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMITt SYSTEM INSTALLED BY
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AUTHORIZATION NO. d 11� OPERATION PERMIT•,B)� \ 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 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.
\ ,DCHD 10/95 .K, f
yT. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �.LY�I 1�e�171E`�'�- / /-/�1"S PHONE NUMBER 7"%����
ADDRESS ���� AYA/F-d SUBDIVISION NAME
C% D C�ZSG�. LOT#
DIRECTIONS TO SITE (O�l /f�� 6(.
Cr (Y4 , . ' �: - ,� �,e,� Vim d . ' 1 use. 07"L !
DATE SYSTEM INSALL D of. NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ILZ��/-- SPECIFY PROBLEM OCCURRING
DATE REQUESTED (D 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 � ( � .(A1,4/2--
Rev.1/93 ZMEEMERN