132 Center Circle Lot 30DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PEAMIT
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**MTEet 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 it of S.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME !A �G�l�iva/� PROPERTY ADDRESS/3aCe-),tkr CI r". - p?"��a� DATE w
LOCATION /. 1.L .. a!> /eoP
C�%: rC ! C
SUBDIVISION NAME 1 // C ' i �!//i fy9���
LOT NUMBER ? c%`�
SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE
# BEDROOMS,7_ BATHS # OCCUPANTS ,y GARBAGE DISPOSAL%.Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE
# PEOPLE # PEOPLE/SHIFT
# SEATS tNDU5TRIAL WASTE: Yes7Noo
LOT SIZE TYPE WATER SUPPLY
AO
DESIGN WASTEWATER FLOW (GPD)
_
NEW SITE REPAIR SITE !/
SYSTEM SPECIFICATIONS: TAW SIZE _ SAL.
PUMP TANK _ SAL. TRENCH WIDTH IMol
ROCK DEPTH 2W LINEAR FT.
OTHER
REQUIRED 511E MODIFICATIONS/CONDITIONS:
teeTHI5 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.
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IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:36 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
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OPERATION PERMIT �7 SYSTEMINSTALLED BY the
PIP
AUTHORIZATION NO. 0:y3 OPERATION PERMIT BY E DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL'INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE It 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-
'y '. .r �.J�r-M:.-�4' 2�'F",:" Y°° 5s ,.• t'j+•. .L. /4p .:µ..� ( ,i ..:"'-tyt '. r.v .��, _ - _
c , o Davie 'County Health Department 77
- ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. ,27028
AUiIIORIZATION FOR WASTEWATER SYSTEM CONSTRNCTION'
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System`Cohstructiod must
issuance of any Building Permits. This Form/Authorization
Office when applying for Building Permits.***
be issued by thiiDavie County Environmental Health Section prior to
Number should be presented to the Davie County. Building Inspections
NAME 4e lUl'iiw/gI ,/T DATEn
J�
NATE ON IMPROVEMENT PERMIT (If different than above)
'SITE LOCATION
COMMENTS/CONDITIONS ON RUTHORIZATION TO CONSTRUCT
WASTEWATER SYSTEM
AUTHORIZATION Nl1+TfER
N2 tO,443
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
+ PHONE NUMBER
ADDRESS /32 (to., v4G<. / tZ' Z SUBDIVISION NAME
/nam 2 7eZY LOT #
DIRECTIONS TO SITE G �ew 5'L,!��" if
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 cerdty 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