147 Green Iron Ln- Perrrtitfee's
DAVIE COUNTY HEALTH DEPARTMENT
Name': +.it "l �- ' `�� Environmental Health Section PROPERTY INFORMATION
r ` r , P.O. Box 848
Directions to property:,- 1^-�'&t`� (- 11dK . ll'� Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTION
AiJTHORIZATION NO: A Road Name: Ji`i7 Zip: .' IX
**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 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�," '� �✓ -, �j l (; IS VALID FOR A PERIOD OF FIVE YEARS.
?NVIRONv1ENTAL'HEALTH SPEC AL1ST' DATE ISSUED
J i GL
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SPECIFICATION: BUILDING TYPE . 0A� # BEDROOMS '�; # BATHS . 7 # OCCUPANTS -GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE t"i'"'" TYPE WATER SUPPLY �^��} DESIGN WASTEWATER FLOW (GPD) ��� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH.al ROCK DEPTH 12 LINEAR FT. 1co
REQUIRED SITE MODIFICATIONS/CONDITIONS: �O(i�
IMPROVEMENT PERMIT LAYOUT
J.A. �C-„"'"
**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:
F417
AUTHORIZATION NO. !�`"� OPERATION PERM T BY: DATE: Jbl/0,C/
o
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT WSYSTEM DESCRIBED WVE HAS BEEN INSTALLED INCOMPLIANCE
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)
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fin-✓ � �`� 3-1
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �r� ��� �' t - — Date .� !
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House _ Mobile Home t_ Business __ Speculation
i
No. Bedrooms —_ No. Baths _ _ No. in Family _.
Garbage Disposal YES ❑ NO E] Specifications for System:
Auto Dish Washer YES 0' NO ❑ �'
Auto Wash Machine YES NO ❑ i
Type Water Supply
1
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements 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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by %ter -
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT 3 01
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By.� 1 1-- 0 br / I ju0?'S (�I? ll
2. Address
3. Property Owner if Different t an Above L'n,i tE%Z1g`f
Address I-
Qq -
4. Permit To: a) InstallVAlter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone 627y —
Business Phone
_,a
c) Sub -Division Sec.— Lot No
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people 1
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions IU X 70
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes urinals
lavatoryshowers
garbage disposal
washing machine
dishwasher sinks f
8. a) Type water supply: PublicPrivateCommunity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
C) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
3-3- X-7
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
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FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1\ ARCA ? f
Date ^I�
Lot Size yZ
AREC AREA 4
1) Topography/ Landscape Position
S
Title ��`���'i�°��''`�
S
CPV-
S
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
tPS
`. - _Com!
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
S
PSS
- P�
S
PS
U
U-
U
U
I) Soil Depth (inches)—
__P�
PSS
PS
U
U
U-
U
i) Soil Drainage: Internal�
LP_ :>
_PS
PS
U
_PS
U--�
U
U
ExternalS
�r
_
P5
S
PS
U
U
U
U
i) Restrictive Horizons
Available Space
P�
- PS�
PS ,
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
cp-8�>
S
PS
U
U
U
U
1) Site Classification
c
U—UNSUITABLE S—SUITABLE PSL -Provisionally Suitable
Recommendations/Comments:
Described by
Title ��`���'i�°��''`�
Date
SITE DIAGRAM
DCHD (6-82)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION (0�2
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME MAT PHONE NUMBER
ADDRESS SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED q NAME SYSTEM INSTALLED UNDER
TYPE FACILITY �6 NUMBER BEDROOMS NUMBER PEOPLE SERVED
/� �,�/ 0
TYPE WATER SUPPLY ( n%1 1 • 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 that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
ST