115 Whitehead Drive Lot 7 Section29
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME J Cil/ Z3 �/1 �S / PHONE NUMBER
ADDRESS � �y�<T� ��`Q SUBDIVISION NAMES-"�u'�`��c
LOT #
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DATE SYSTEM INSTALLED 16W NAME SYSTEM INSTALLED UNDER �v
TYPE FACILITY f- NUMBER BEDROOMS NUMBER PEOPLE SERVED/
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
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DATE REQUESTED �'-2�' G INFORMATION TAKEN BY
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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
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AUTHORIZATION NO: —A i 0 DAVIE COUNTY HEALTH DEPARTMENT "G
Environmental Health Section PROPERTY INFORMATION
Permittee's"''1"" -r- ` . " P.O. Box 848 yam! �✓ .L%��`'r/�"'
Name: � , C�f{'� Mocksville, NC 27028 Subdivision Name: '�'f` , J
J Phone # 336-751-8760 C Lot:
Directions to property:// -5 ��ii1 G� Section: Siy
J yy AUTHORIZATION FOR
WASTEWATER Ta i e I #
SYSTEM CONSTRUCTION
R %t Zip: Z7J�
**NOTE** 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.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVI ONMENTAL HEALTH SPECIALIST DATE ISSUED
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y DAVIE C®iJNTYIEAI,TI� DEPAItT1VIENT`'''
i �{ RMITS PROPERTY INFORMATION
IMPROVEMENT AND OPERATION PE
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Nam Subdivi'sion Name:<r
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Directions to'property ' + r7' �°/If ,3 '. ' do +� Lot:
Section:
ROVEME NT J
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PERMIT ZAra
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**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,,
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:
construction/installation,of a,system orthe issuance of a building permit.
(Incompliance with,Article.l I .of G.S. Chapter:130A, Wastewater Systems, Section .1900 Sewage.Treatment.and Disposal. Systems)
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** NOTTCE THIS PERMI IS SUBJECT TO REVOCATION IF S
PLANS OR THE INTENDED USE CHANGE. YOUR WAS
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SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE'` z
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING SYSTEM.it
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RESIDENTIAL SPECIFICATION: BUILDING TYPE _,1�/ # BEDROOMS *BATHS # OCCUPANTS _� GARB F
AGE,DISPOSAL Yes or No
COMMERC IAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #'SEATS INDUSTRIAL WASTE Yes o No
LOFS�IZ E / ,TYPE WATER SUPPLY l DESIGN WASTEWATER FLOW (GPD) .NEW SITE ' REPAIR SITE Lr -r
SYSTEM SPECIFICATIOT�ANK SIZE Gkt/'• PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH.- � -LINEAR FT
* *w Y $ rH
OTHER.
REQUIRED SITE MODIFICATIONS/CONDITIONS:` 01°i n
E1D'" FL.L6ENT FILMERik, *RI RIS) IF 6" BEL014 f IN
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IMPROVEMENT PERMIT LAYOUT
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"CONTACT A REPRESENTATIVE OF THE.DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OM -AW& "7' 0
'n .. BETWEEN 8.30 ,9:30 A.M: OR 1;00 1;30 P.Ni' ON THE DAY OF INSTALLATION. TELEPHONE # IS (-784').
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OPERATION PEft4IT
L ED BY:
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AUTHORIZATION NO. ` .OPERATION PERMIT BY:, DATE,
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"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 BETAKEN ASA ;.
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY.GIVEN PERIOD OF TIME.
y DCHD 05/96 (Revised) " '