256 Boxwood Church Rd (2) DAVIE COUNTY HEALTH DEPARTMENT L;3 D VX o
IMPROVEMENT PERMIT and OPERATION PERMIT Z�
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 it of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME r ''�/� rs"O.t� PROPERTY ADDRESS d � iC- DA I� 1
LOCATION /�r15<1�1a�'�G� �'�!'/P,�� �Pl [����Pk, �d�SP O'er •�y�
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE , TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)
-�o— NEW SITE t,,-' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE &a GAL. PUMP TANK GAL. TRENCH WIDTH _ ROCK DEPTH _J y� LINEAR FT. t%)
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.
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.
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OPERATIONPERMIT SYSTEM INSTALLED BY �Ar'�V Yh'�I I1A
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AUTHORIZATION NO. OV OPERATI PERNBY Y" DATE 31D" 7-
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE 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.
DCHD 10/95
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
constructiooYinstallatiOn of,a system,or the issuance of a building permit.
(In compliance with Article 11 of 6.5. Chapter 130A, Wastewater Systems, Section .1906 Sewage Treatment and Disposal Systems)
NAIff /1_ // frS A PROPERTY ADDRESS DATE I>
y
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER w
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS 41 # BATHS '� # OCCUPANTS i GARBAGE DISPOSAL: Ye
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No t
LOT SIZE ,1/ TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) -!�-I?j9 NEW SITE .REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH —?j� ROCK DEPTH Jt, ,' LINEAR FT.
, 0d
OTHER' r`
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.
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I
i
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTIQN OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.W. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
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AUTHORIZATION NO. OD OPERATI PERM BY Y\q C"L DATE I
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAf 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. .
DCHD..14/95
,► Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SY5TEM CONSTRUCTION
(Issued in compliance with Article 11 of
` B.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.***
� AUTHORIZATION NUMBER
NAME —�IA. A4LSO *'t DATE N2 i
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**;NOTICE*** THIS AUTHORIZATION FDR STEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (S) YEARS.
ENVIRONMENTAL HEALTH SPkIALIST DATE
DCHD 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE
Davie County Health Department .`
Environmental Health Section OCT 12 199� i.
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By fl A flu er r�o �u-
Mailing Address a � 0 x W 0 0 d of `` 01. a Home Phone
a 7,02 X Business Phone O 02 7G"��
2. Name on Permit if Different than Above `
3. Application for: ❑General Evaluation J Septic Tank Installation Permit ..
4. System to Serve: ❑ House f Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine z,
No. of Bathrooms / ❑ Dishwasher
Dwelling Dimensions ' X �l/ ❑ Garbage Disposal !i
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6. If business, industry, place of public assembly, other: Specify type I
No. of People Served No. of Sinks �•
No. of Commodes No. of Urinals t
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No. of Lavatories No. of Water Coolers r
k
No. of Showers Water Usage Figures
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7. Type of water supply: [ Public ❑ Private ❑ Community
8. Property Dimensions 94242,41,&--, Sewage Disposal Contractor
. 1.
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No
If yes, what type? 1
i
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to !.
revocation, if site plans or the intended use change. Effective October 1, 1989. g
1:
PROPERTY INFORMATION REQUIRED:
PIN Office
Directions to Property: Tax
Road Name —�?0 /K I)06(- C�i1
Box # (if available)
oKw00 L'/►• CityAl,ke_l�oC sy ll�
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This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
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DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: J$I 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized represerDta4ve of the D vie County Heath Depa ent to enter upon above described
property located in Davie County and owned by face-��l 1� �A �-1c�r'�c t
to conduct all testing procedures as necessary to det mine said site's suitability for a ground absorption sewage treatment
and disposal system. _
DATE SIGNATURE
DCHD(1/93) p;
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