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1 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 I36A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
WE / IIAI/ PROPERTY ADD
RE55 L� DATE 3 iY'r9l
LOCATION /1/a✓.Y° d�//✓/� �r�
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL'SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/0
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPtE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No,
LOT SIZE TYPE.WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) P—C�,d NEW SITE REPAIR SITE d/r
SYSTEM SPECIFICATIONS: TAN!( SIIE GAL. PUMR TANK GAL. TRENCH WIDTH 36 ROC DEPTH bLINEAR FT.coo
OTHER .�"• ;`'�... ..
a
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.
1
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IMPROVEMENT PERMIT BY
77
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:N-1:30 P.M. ON THE DAY OF INSTALLATION. . TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
15
AUTHORIZATION NO. p� 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 NOWAY BE TAKEN AS A !
GUARANTEE:THAT`THE.SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. I
DCHD 10/95 .:
r,\
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
},IMPROVEMENT PERMIT.
w **NOTE** This improvement permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater
system. AN AUTHORIZATION.y0'WASTEWATER SYSTEM CONSTRUCTION-lust-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 - � 'f��r r� I,i l�- PROPERTY ADDRESS 6 ?2141 DATE
LOCATION .ri���;�.,�
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER s �i
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/9-0
COMIMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes//N
LOT,51ZE -TYPE WATER SUPPLY DESIGN*WASTEWATER FLOW (GPD) lj NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS:'TAM#( SIZE' GAL. PUMP TAME( GAL. TRENCH.WIDTH ROCK DEPTH / ''�- LINE0 FT. _
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: rt' ►
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE-INTENDED USE CHANGE. ,YOUR WASTERWATER SYSTEM CONTRACTa MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY,HEALTH DEPARTMENT FbR FIMAIjINSPECTION O 'THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:N-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE'S#_,IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY _/�aw"2
�i
AUTHORIZATION NO. y _ OPERATION PERMIT BY �'� '—� DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE ll.OF G.S. CHAPTER 130A, SECTION :1900 "SEWAGE TREATMENT ANII_DISPOSAI.:SYSTEMS", BUT 5HAlL IN.ND WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. '
` DCHD 10/95 f t 4Y
• '� f .�'h .I.. • .., w 7 `P'Y1..7 "r ..-„t-1.�' -'aar. .rf.^T 4.:�h Xr .SY. . T .. y - 1 Y . i r {
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER 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 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.***
1-0 NAME P/ %gf0DrCa DATE o rJJ�Jy AUTHORIZATION NUMBER
NAME ON'IlPROVE m PERMIT (If.different than above)
SITE LOCATION
ty.
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM -
**QOTICE+#a THIS AUTHORIZATIO WASTEWATER SY EM STR S R PERIOD OF FIVE (5) YEARS.
ENVIRMWAI HgLTH\SjECIALIST DATE
DCHD 10/95
. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
CY
ADDRESS /-/"
DDRESS SUBDIVISION NAME
S �i9/-S an LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY bhSY' 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 knowled Pd at I u rsta I espo ib for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.t/93