P0401 Vanzant Rd -...w..�.L-. 1.1.1u�.y1 .r..f:.t 11 .' -� .:`i^•".: V.r.A_+.) 4..6.- . .;'Y'.r-�')ysltii Y-• _ _ . .i .. ..... .. -
DAVIE COUNTY HEALTH DEPARTMENT
-j 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)
NAME //1/'/' ; a PROPERTY ADDRESS __Va-- t- a-n�- . v� /Do'{ DATE •
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE 11066te # BEDROOMS V # BATHS ,2 # OCCUPANTS LP GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No/
LOT SIZE TYPE WATER SUPPLY / (, DESIGN WASTEWATER FLOW (GPD) 7;1,4) NEW SITE REPAIR SITE t/
SYSTEM SPECIFICATIONS: TANK SIIE GAL. PUMP TANK GAL., TRENCH WIDTH, .�`� ROCK DEPTH 1� LINEAR FT.
OTHER
t
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.
�o
IMPROVEMENT PERMIT BY Ala /
r
**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 ^ Y TALLED B
V�
p �
Y
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.
DCHD 10/95 i
�" .n„ ia...v.n..} h..✓.._� -a•.:..i ... .-..T . s. �••4•.b M.n.-..i a:Y <.a w'J'i ,. .a ... . -. -- -.... -_
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVPERMIT
**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)
NAME 14,r ' /i /G'��j: PROPERTY ADDRESS VA-K a7'I� CL, !� DATE
�/ i.40
LOCATION ��,d';JjiJ A�
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTALYSPECIFICATION: BUILDING TYPE AM-re # BEDROOMS. # BATHS # OCCUPANTS LP GARBAGE DISPOSAL: Yes/No
COMMERCIAL. SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No/
LOT SIZE TYPE WATER SIMPLY '�. DESIGN WASTEWATER FLOW (GPD) X11 NEW SITE I REPAIR SITE �l
SYSTEM SPECIFICATIONS: TANK SIIE/ GAL. PUMP TRM6( GAL. TRENCH WIDTH f ROCK DEPTH /� l LItAA FT. .
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.
toft,ft,
IMPROVEMENT PERMIT BY /T/d
**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 Y ;T ED rD
led
1
AUTHORIZATION NO. �1112�/ 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 FLNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
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.***
,�..yy�� / / AUTHORIZATION NUMBER
NAME //// I DATE ZZ?Vlo'l N2 0 01
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATIONZPG'
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**{NOTICES THIS AUTHORIZATION FQ WA TEWATER 5Y TEM pONSTRLICTIQN I ,,VALID FOR A PEFIOD,QF FIVE (5) YEARS.
ENVIROA ENTAL HEALTH C ALIST DATE
DCHD 10/95
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) J
NAME A/azt, PHONE NUMBER
ADDRESS ZX.� �1�11��if/ ��'' SUBDIVISION NAME
LOT#
DIRECTIONS TO SITEj��
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY a 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 at I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93