990 Dulin Rdr
4 w
4 3 6 Sq. ft.
OPERATION PERMIT
o-
Davie County Health Department
-
210 Hospital Street
0 9 ft.
P.O. Box 848
Mocksville NC 27028
Phone: $36-753-6780 Fax: 336-753-1680
Applicant: Kelly Watts
Address: 8166 Reid Cook Rd
CRY: Catawba
StatefLip: NC 28609
Phone #:
P
Address/Road #:
990 Dulin Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: NIA
�roperty Owner: Kelly Watts
Address: 8166 Reid Cook Rd
City: Catawba
StatefZip: NC
'Phone #:
ierty Location & Site Information
Subdivision: Phase:
Directions
Hwy158, right on Dulin Rd
*IP Issued by
*CA issued by: 2140. Nations, Robert
Design Flow: 4 8 0
Soil Application Rate: 0 a 7 S
Lot:
*System Classificatan[Description:
TYPE 11 A..CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SeproliteSystem? QYes ANo
*Distribution Type: GRAVITY- SERIAL Pump Required?
QYes rNo
*Pre Treatment:
J
Drain field
Nitrification Field
4 3 6 Sq. ft.
No. Drain Lines
Total Trench Length:
1
0 9 ft.
Trench Spacing:
Inches O.C.
— Feet O.C.
Trench Width:
3 Inches
— &Feet
Aggregate Depth:
inches
Minimum Trench Depth: 2
4
Inches
Minimum Soil Cover. 1
2
Inches
Maximum Trench Depth: 3
6
Inches
,aximum Soil Cover. 2
4
Inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Randy Miller
Certification #: 1128
*EH S: 2140 - Nations, Robert
Date: 0 4/ 1 1 / 2 0 1 6
Approve[ Status r
® Approved Q Disapprovedig
CDP File Number 202226 - 1
} 5759.78.2111
Countv ID Number:
Manufacturer.
Installer.
Let.
Dosing Volume:
—
Gallons:
Long:
,
STB:
Date:
*EHS:
*Chain:
RiserSealed ❑
Gallons:
❑
No
RiserHe0t: ❑
Installer
❑
Date:
/
Yes
/
Certification #:
1 Piece Tank: ❑
Yes _.._
'
NO
❑
NO
*EH S:
*Filter Brand:
❑ Yes
inch diameter
NO
Pipe Length:
`App-h*61 StatusJ011-
feet
ST Marker.
❑
Yes
❑
No
Date:
Pressure Rated El
nforced Tank:
El
Yes
11
No
Yes
�� �ApprovalStetus
No
1 Piece Tank:
11Yes
\ Anti -siphon Hole
❑
N o
No
❑ Approd ❑ Dl
#- vesapprovetl
v %.
, r
Pump Tank
Installer.
Certification #:
*EH S:
Date:
Manufacturer.
Installer.
PT:
Dosing Volume:
—
Gallons:
Draw Down:
Inches
Date:
*EHS:
*Chain:
RiserSealed ❑
Yes
❑
No
RiserHe0t: ❑
Yes
❑
No (MIn. 6 in.)
Reinforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes _.._
_ ❑
NO
❑
NO
Pipe Size:
❑ Yes
inch diameter
NO
Pipe Length:
`App-h*61 StatusJ011-
feet
❑Yes
*Schedule:
No
❑Approved
❑
Pressure Rated El
Yes
1:1No
❑
No
Approved fittings ❑
Yes
❑
No
u �rtr�vir.Mu vwc��prw�a.v
upply Une
Installer.
Certification #:
*EH S:
Date: / 1
/ Pump Type:
/
Installer.
Dosing Volume:
—
Gal Certification #:
Draw Down:
Inches
*EHS:
*Chain:
Date:
Valves Accessible
❑ Yes
❑
No
Flow Adjustment Valve
❑ Yes
❑
NO
Check -valve
❑ Yes
❑
NO
`App-h*61 StatusJ011-
PVC unions
❑Yes
❑
No
❑Approved
❑
Disapproved
Vent Hole
❑ Yes
❑
No
\ Anti -siphon Hole
❑ Yes
❑
No
4 ••
CDP File Number 202226 -1
Electric Eauinment
County ID Number: 5759.79-2111
NEMA 4X Box or Equivalent
❑ Yes
❑
No
Installer:
Box 12 inches Above Grade
❑
Yes
❑
No
Certification #:
Box Adj.To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
*EHS:
Pump Manually Operable
❑
Yes
❑
No
*Activation Method:
Date:
Alarm Audible
C3
Yes
❑
No
Approval Status
❑Approved❑ Disapproved
Alarm Visible
❑
Yes
❑
No
e
2140 - Nations, Robert
*Operation Permit completed by.
Authorized State Age
Owner/Applicant Signature:
Date of Issue: 0 4/ 1 1/ 2 0 1 6
This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq., and all conditions of the Improvement Permit and
_.Construction Authorization. This property is served by a TYPE Ila sewage septic system.
Rule -.1961 requires that a Type TYPE II a septic system meet the following criteria:
Minimum System Review By The local Health Department: N/A
Management Entity: OWNER
Minimum System InspectionrMaintenance Frequency ByCedified Operator:
N/A
Reporting Frequency By Certified Operator. NIA
Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
a Hand Drawing 41mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksvdle NC
Drawing Drawing Type: Operation Permit
CDP File Number: 202226 - I
County File Number: 5759-78-2111
27028 Date:
Olnch
Scale: OBlock
ON/A
M
Applicant: Kelly Wafts
Address: 8166 Reid Cook Rd
City: Catawba
State/Zip: NC 28609
Phone M
Address/Road M Subdivision:
990 Dulin Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: NSA
/ For Office Use Only
*CDP File Number 202226 -1
County ID Number. 5759-78-2111
Evaluated For: EXPANSION
Township:
PERMIT VALID UNTIL:
0 4/ 0 4/ a 0 a 1
Property Owner: Kelly Watts
Address: 8166 Reid Cook Rd
City: Catawba
State/Zip: NC
Phone M
Phase:
Hwy 158, right on Dulin Rd
28609
Lot:
CONSTRUCTION
Minimum Trench Depth:
AUTHORIZATION
°"•-
Davie County Health Department
(Vo,
210 Hospital Street
P.O. Box 848
Saprolite System?
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Kelly Wafts
Address: 8166 Reid Cook Rd
City: Catawba
State/Zip: NC 28609
Phone M
Address/Road M Subdivision:
990 Dulin Road
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: NSA
/ For Office Use Only
*CDP File Number 202226 -1
County ID Number. 5759-78-2111
Evaluated For: EXPANSION
Township:
PERMIT VALID UNTIL:
0 4/ 0 4/ a 0 a 1
Property Owner: Kelly Watts
Address: 8166 Reid Cook Rd
City: Catawba
State/Zip: NC
Phone M
Phase:
Hwy 158, right on Dulin Rd
28609
Lot:
Page 1 of 3
Minimum Trench Depth:
a 4 Inches
\Site
Classification:
Provisionally Suitable
Saprolite System?
O Yes (&No
Minimum Soil Cover:
1 a Inches
Design Flow:
4 8 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate:
0 a 7
5
Maximum Soil Cover:
a 4 Inches
*System Classification/Description:
*Distribution Type:
GRAVITY - SERIAL
TYPE II A. CONV SYSTEM (SINGLE-FAMILY
OR 480
GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 25% REDUCTION
1 -Piece:
O Yes O No
Pump Required: O Yes
®No O May Be Required
Nitrification Field
4
3
6
Sq. ft. Pump Tank:
Gallons
No. Drain Lines
1
1 -Piece:
OYes ONo
Total Trench Length:
1 0 9
GPM --vs— ft. TDH
ft
Trench Spacing:
—
9
OInches
®
O.C.
Feet O.C. Dosing Volume:
—Gallons
Trench Width:
3
OInches
®
Feet
—
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre -Treatment: O NSF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: 01011
O 111 O IV /
Page 1 of 3
CDP File Number 202226 - 1
r
,"Repair System
*Site Classification: Provisionally suitable
Design Flow: d R pl
County ID Number: 5759-78-2111
❑ Open Pump System Sheet
®Yes O No ONO, but has Available Space
Soil Application Rate: 0 - a 7 5
*System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
1 7 4 5 Sq. ft.
a
436 ft.
Trench Spacing: _ 9 O Inches O.
® Feet O.C.
Trench Width:_ 3 O Inches
f� Feet
Aggregate Depth:
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
a
4
Inches
*Distribution Type: GRAVITY - SERIAL
Pump Required: OYes .®No O May Be Required
Pre -Treatment: O NSF OTS -1 OTS -11
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. RhM=
750
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. Rh,
afning
2000
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not
to exceed five years, and may be issued at the same time the Improvement Permit issued (NCGS 130A -336(b)). If the installation has not been
completed during the period of validity of the Construction Permit, the information submitted In the application for a permit or Construction
Authorization is found to have been incorrect, falsified or changed, or the site is altered, the permit or Construction Authorization shall become
invalid, and may be suspended or revoked (.1937(8)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? O Yes ONO
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140 - Nations, Robert
Authorized State Agent: If
Date of Issue: 0 4 / 0 4 /.2 0 1 6
Malfunction Log OYes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
A
- CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 202226 - 1
County File Number: 5759-78-2111
Date: 04 /04/,2016
O Inch
Scale: , O Block
O N/A
Click below to import an i
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 202226-1
P.O. Box 848 5759-78-2111
Mocksville NC 27028
County File Number:
Date:.O.4./.0.4./...0.1.6
le from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
9 �14DAVIF- COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Mocksville, NC 27028 Subdivision Name:
Directions to property: J" Phone Section: Lot:
AUT # 336-751-8760 AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CtONSTRUCTION
U j2k4A % N W Road Name: Zip:
[**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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
A IT 'el IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTALHEALTH ECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE �_ # BEDROOMS _.� #BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACIIITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) - NEW SITE REPAIR SITE _ z
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH .? G ROCK DEPTH ZZ LINEAR Fr. /-Ca
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER* *RISER(S) IF 6" BELOW FI(IISHED GRADE*
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 (WW**N.R
t 7�t:17S 1 —P7f P
OPERATION PERM r C'
SYSTEM INSTALLED BY: 1
AUTHORIZATION NO. l 9�� OPERATION PERMIT BY: �t ` G l l DATE:
-7—
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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 05/96 (Revised)
2�D
Pemtittee'sDAME GOUNTY HEALTH DEPARTMENT
Name: _Cea�/ R: �VLe2 * Environmental Health Section PROPERTY INFORMATION
i y P.O. Box 848
Diree6an"vproperty: l ( j r Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
7rAj, AUTHORIZATION
OR �1
C SGY�STW CON TRUCTION,/ y1a
Office PIN:# �lS/c L -- �i1I
AUTHORIZATION NO: 2355 A / q � ,AIA . / �/ kold Name: —41— 0% Zip:
**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 11 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.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE IV # BEDROOM$ , --3 # BATHS a # OCCUPANTS 1-31 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) F NEW SITE REPAIR SITE
��
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 4 ROCK DEPTH L
k.INEAR Fr. 1_17 i�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PER1,4IT LAYOUT�,�(,j,� - -
td�!1 >I
0ty
./0
**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 (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
UW /(
C
AUTHORIZATION NO. OPERATION PERMIT BY: 11WA —112DATE;•,
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE BEEN INSTALLED IN
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", B HALL IN NO WA)
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHo0=tR�.rwdl 3a 3 i
✓
ASA
6A0
Permittee's _,7DAVIE COUNTY HEALTH' DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 8.48.
Directions to property:{ Z' '.ir ; , }' `[%! Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER ; _ —f
Tax Office PIN:# 5='
SYSTEM CONSTRUCTION �l l
AUTHORIZATION NO: ' A Road Name: •Lt.:L. Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
�/Authorization Number should be presented to the Davie County Building Inspections
to issuance of any Building Permits. This Fon
Office when applying for Building Permits.
(In compliance with Article 11 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.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
i
RESIDENTIAL SPECIFICATION: BUILDING TYPE 1'�' #BEDROOMS ,--3 # BATHS # OCCUPANTS V GARBAGE DISPOSAL` Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY~ DESIGN WASTEWATER FLOW (GPD),.E-% NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK - GAL. TRENCH WIDTH ROCK DEPTH LINEAR Fr.
OTHER .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PE{IJ IT LAYOUT, - - -
dtf
**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 (336)751-8760.
OPERATION PERMIT r e
SYSTEM INSTALLED BY: D C/
AUTHORIZATION NO.C22& 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 02/02 (Revised) .3
o`N✓ � � g'f�,
hi y 17 04 DO: 57a. .-davie county envhealth 336 751 8786 P.2
APPUCMION FOR SITE EVAWATION/1MPROVEMFM PERMIT & ATC
`• Davie County Health Department
&Virommnta/Health SOCUOn
P-0. Box 848/210 Hospital Street
Mocksyille�...NC 27028
(336) 751-8760
***ZMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED., Refer to the INFORMATION BULLETIN for instructions.
�1. Name to be Billed uoatn Contact Person_ Ccthe-
✓ Mailing AddressCq1 Home Phone �33fo�' ���®' y35
-:9-7112bBusiness Phone ong3 r�C_City/state/ZIP�
L-2. Name on Permit/ATC if Different than Above sQMN�
---Mailing Address <0VV%e City/State/Zig _ SO111V
—_3_ For: ❑ Site [svaivation PO Improvement Peewit/ATC ❑ Both
system to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ other
�S. Type system requested: Conventional ❑ conventional modified ❑ innovative
J-6. If Residence: People r _ R Bedrooms # Bathrooms 2
`r❑Dishwasher. ❑Garbage Dispcaal 29Wishing Machine I3Basement/Plumbing RlBasement/No Plumbing
7. if Business/Industry /others verify type at People A Sinks
Commodes # Showers tt urinals - # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
4--8. Type of water supplys Country/City ❑ Well ❑ Community
t
9. bo you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes j(No
Ifyes, what type?
***IMP tTANTt** CLIENTS MUST'C -& THE REQUIRED PROPERTY INFORMATION REQUESTED
OIV, ither a PLAT orSITE PLAN MU T BE SUBMITTED by the client with THIS APPLICATION.
r 1y Qinunsions: a�.�?J acarts3:. L_,XRITE DIRECTIONS (from A•locksville) to PROPERTY:
��arx+OfRce PIN:
T– J
-operty Address: Road Name �.1 ~ NO
City/Zip _ Yj
If In a Subdivision provide Information, as follows:
Name:
Section: Block: y Lot: L DATe home corners flagged:'
O
.. This is to certifythat the information rc.vided is correct to the�est of my luiowledge. I understand that any erntlt(s
P P
Issued hereafter are subject to suspension or revocation, if the site plans or Intended use change, or If the information
submitted in this application is falsified or changed 1, also, understand that f aha responsible for all charges incurred from
this applicatiom I, hereby, give consent to the Authorized Representative of the Davi 'onnty eaItl1 Departmcut
to enter upon above described property located in Davie County and: owned by
to conduct all testing procedures as necessary to determine the site suit ilty.
ce
DATE t�' .._ cl-OtGNATURE
THIS AREA MAYBE USED FOR DRAINING YOUR SITE PLAN (Includtile following: Exisfing and proposed
property tines and dimensions, structures, setbacks, and septic locations).
-�-----�
E
f(
1
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_ ; Davie County, North Carol�ina Spatial Data Explorer Page 1 of 2
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• County ID: G600000078
• Account Number. -82522032
• PIN: 5759782111
• Legal 1:5 AC DULIN RD
• Owner Name: FOSTER PAUL E & ROY SR
• Owner/Address 1: FOSTER PAUL E & ROY SR
• Owner/Address 2: CARTER ADDIE MAY
• Owner/Address 3:268 CAROLINA STREET
• City,State Zip: MOCKSVILLE ,NC 27028 - 0000
• Land Value: $45,610.00
• Building Value: $62,470.00
• Land Unit / Type: G600000078 :l AC
• Deed Book/Page: 2003E / 0136
• Deed Date: 2003/05/19
• Sales Price: $0.00
• Property Address:
000990 000990 RD
• County Zoning:
• Census Code:
• City Code:
• Fire District:
• Flood Zone: ZONE X
• Flood Community:
• Flood Panel:
• Flood Map Date:
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• AUTf-t�RIZATION NO • � � � �'DAVIE;COUNTY HEALTH DEPARTMENT
"'� `` ' `. Environmental Health Section PROPERTY INFORMATION '
Permittee's ;,�`c ` P.O. Box 848 �.
Name: ���' z"��1 `"C"./�� ; Mocksville, NC 27028 .'. Subdivision Name:
, �a-/ Phone # 336-751 `8760
Directions to property:' �� ,�c� �i�� ���(� Section: Lot:
/ AUTHORIZATION FOR
,.�/f ' ` WASTEWATER
___ ,�:_/,(`/C'�S^[�" �%/1" Tax Office PIN:# - -
� � SYSTF.M CONSTRUCTION ' �
Road Name Zip:
**NOTE** This Authorization for WastewaterSystem Construction MUST BE 1SSUED by the Davie Counry Environmental Health Section prior
to issuance of any,Building`Permits.: This Form/Authonzation Number should be presented to the Davie Counry Building Inspections
, , . .
Office when applying for Building Permits. , > � ' � � � '-: ,
'(ln compliance with Article l l. of G.S; Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
%� � <: ***NOTICE*** THISAUTHORIZATION FOR WASTEWATER CONSTRUCTION
��� '"" �`,;I,T `Zi/ :IS VALm FOR A� PERIOD OF FIVE YEARS. °�
` ENVIRONMENTAL HEALTH ECIALIST `: DATE ISSUED
'4DAVIE COUNTY HEALTH DEPARTMENT *,
��'`
IMPROVEMENT AND OPERATION PERMITS. PROPERTY INFORMATION
Permitfee's''
•Name: '`' Subdivision Name:
w.
`Directions to property: _-{°r T. Section: Lot:
U"ROVEMENT
PERMIT Tax Office PIN:# - -
Road Name: Zip:
t **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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
,%} PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER .
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS _ .2_ # BATHS # OCCUPANTS _� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS, INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� Ca .� ROCK DEPTH Z.Z LINEAR FT. �
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
�''"` 't a+� ,d,,''w,.w;.,.,..�.r � �:���� �!%'+`l,_ ��~:5-» . Ka ,'jam t `,i'., i,. `.•.fa „,�. *': . ,y .�d'" °r-` `•�'' a,.« '.l .s. > _ y'
• '4.s -`9 1 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's / r .
Name: f 'fr':' , f '; i'. .r Subdivision Name:
Directions to property:Section: Lot:
" IMPROVEMENT
PERMrr Tax Office PIN:# -
Road Name: Zip:
**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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) '
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL �IEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS_ #,,BATHS # OCCUPANTS –j— GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION:. FACILITY TYPE # PEOPLE # PEOPLE/SHIFT'# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE ---L REPAIR SITE Z
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 7 ROCK DEPTH � � LINEAR FT. ,_,Lr(1,
a
i
OTHER _ 4
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFUIU4T FILTER* *RISER(S) IF 6'9 BELM FINISHED;'GRAI)E*
s
**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
C—1r,)751-e9b
M
R
n
OPERATION PERMIT
Uy
SYSTEM INSTALLED BY:
i 1 ,
AUTHORIZATION NO. OPERATION PERMIT BY, DATE: .
Y.f
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL I� DICATE 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 QF TIME.
rerun n,woF iv—;..A�
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME �� PHONE NUMBER
ADDRESS % D n./ __L____SUBDIVISION NAME
4 / l S- '�'l � /�d � 't/ C— LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY . NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED
FORMATION TAKEN
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. 1/93
'„t-.,^^F�^1_'7�\. ,7,""�T�"L'S• `rn.^,T�'!�.�,...ww-'...�.r.: ._•.�.±. ,.:i^•�7,«�`
Permtei s DAVIE COUNTY HEALTH DEPARTMENT
I�tame �i A i _ Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
Q,( Phone #: 336-751-8760
Section:
Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#S�?S1�'- '2--, -2j//
SYSTEM CONSTRUCTION
- AUTHORIZATION NO: 2355 A Road Name:_- 2, A% Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen -nits. This Form/Authorization Number should be presented to the bavie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r �> : '`= f!`r .',• . % IS VALID FOR A PERIOD OF FIVE YEARS. i
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
t
RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS �A' # BATHS # OCCUPANTS �!mL GARBAGE DISPOSAL'. Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No a
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
- �lt, k, i
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL TRENCH WIDTH �� ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PE,JIT LAYOUT - — -
' a Wit
rte. D�
q'
"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 (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: