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` a� 1. DAVIE COUNTY HEALTH DEPARTMENT60
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IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
pephij,as
l Name. --. �/ d 7", Subdivision Name:
t
rt=-flirections to property:,.- Section: 'l.ot:
. ✓ IMPROVEMENT
PERMITTax Office PIN:# - -
Road Name: Zip:
**NOTE**This Improvement nt Pemit DOES NOT authorize the construction or installation of a septic tanks stem or any_wastewaters stem.An
P
t AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
P
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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPE IALIST ' DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE Z&& #BEDROOMS,-_#BATHS_—:L#OCCUPANTS--IV,,GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEM LINEAR FF.,�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
REFFLUEN FILTER* *RISER(S) IF 61' BELOW FINISHED GRADE'
**CONTACT A REPRESENTATIVF.OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR :30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
xxxxxxxxx
OPERATION PERMIT
M INSTALLED BY:
r
AUTHORIZATION NO. J OPERATION PERMIT BY: G"— 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.
DCHD 05/96(Revised)
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755
DAVIE COUNTY HEALTH DEPARTMENT 6 0
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
jr
.vi, P�yfnita�'S '.:,Y,.
Nam"e1 ,� r'' R . Subdivision Name:
t D11ctions to property: r� '°` t{ •� Section:
r' IMPROVEMENT
r°"{ PERMIT+ Tax Office PIN,:# - -
Road Name: Zip:
- x **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 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE all #BEDROOMS ? #BATHS--�)—#OCCUPANTS�-GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No t'
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE f
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANKGAL. TRENCH WIDTH ROCK DEPTfrLINEAR FT. .� 02
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
PPRt]6 D EFFLUL FILTER* *RISER(S) IF 61' BELOW FINIS14ED GRADE*
et
**CONTACT A REPRESENTATIVZOF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR :30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
XX?SXXXXXX`
OPERATION PERMIT
INSTALLED BY: L/!/�./L�L(��� I�'f C ,dI`
i
1
AUTHORIZATION NO. /f 5e� OPERATION PERMIT BY: " ` 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.
DCHD 05/96(Revised)
:A 1 ,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
4PPLICATION
FOR IMPROVEMENT PERMIT(REPAIR)
NAME G PHONE NUMBER
ADDRESS G ! ��^ SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED 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
Rev.1/93