126 Ashley Brook Ln Lot 3 r xo
Davie County Health Department c�
"* �.; ENVIRONMENTAL HEALTH SECTION ,
P.D. Box 665
Mocksville, N.C. 27028 c
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 13OA, 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�BuildingjInspections
Office when applying for Building Permits.***
AUTHORIZATION NIMER
NAME Z� O DATE N7 0 9
v 5
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION P ci���
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*HNDTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID'FDR A PERIOD OF FIVE (5) YEARS.
ENVIRON ENTAL'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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME \), e�z`G� PROPERTY ADDRESS a G TN AA oo\C\ DATE 5-6 9 L.
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE bus¢ # BEDROOMS ) # BATHS # OCCUPANTS ZJ GARBAGE DISPOSAL.: Yes/No
COMMERCIAL SPECIFICATION `FACILITY TYPE # PEOPLE # PEOPLE/SHIFT, # SEATS INDUSTRIAL WASTE: Yes/No-
LOT SIZE oxjN" TYPE WATER SUPPLY U JZa DESIGN WASTEWATER FLOW (GPD) 6 b NEW'SITE REPAIR SITE.
SYSTEM SPECIFICATIONS: TANK $IZE f oab 6AL. PUMP.TANK GAL. TRENCH WIDTH' 3 �'ROCK DEPTH � LINEAR FT. dy-(
OTHER '`• w °
REQUIRED SITE MODIFIPTIONS/CONDITIONS
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE C . YOUR WASTERWAER SYSTEM CONJRACTOR POST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
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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 ���t��-�-� +—� `►��
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AUTHORIZATION NO. 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.
DOHD 10/95
All
• 1.
DAVIE COUNTY HEALTH DEPARTMENT '
R aid" ;��ar •• IMPROVEMENT PERMIT and OPERATION PERMIT
' IMPROVEMENT PERMIT
**NOTEf This m�rovement 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 �'�Oy,p>1 c PROPERTY ADDRESS ' G NN s\`P\t V)V.cv V,14 DATE r-b`' too
LOCATION ( -� N 4-t\ �� `c.�-s s� >� r I� s•� — � `e�c � �k-.z ��4
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE ave # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION:`FACILITY TYPE #PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE ox N_ A TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 6 0 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/_LGAL. PUMP TANK GAL. TRENCH WIDTH'_ ROCK DEPTH LINEAR FT. dy I
OTHER ^.
" REQUIRED SITE MODIFICATIONS/CONDITIONS:
0.,,„„ ***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. w
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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 a�� �
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AUTHORIZATION Na. OPERATION PERMIT BY- DATE
**THE ISSUANCE OF THIS OPERAT;ON PERM T SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF B.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" :
aro uouft q r'�- qz yroera CT l
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME 2121 LP- OVerrbil PHONE NUMBER
ADDRESS 4.S ICO 9466 k* .Z;71 - SUBDIVISION NAE ai'�isd
a ct::5- 7d LOT#
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DIRECTIONS TO SITE 0�71_,' /7 le/4 �Id d K �72 . ( �6 1 rcl,
DATE SYSTEM INSTALLED - NAME SYSTEM INSTALLED UNDER
TYPE FACILITY D NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY 7VZfl SPECIFY PROBLEM OCCURRING Gt S la'262 ;)t
DATE RL%&WEEY-�^� 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.1193