652 Hwy 801Si 7
Permittee'$ / d`' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
".,,,Directions to property: If, Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR '
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
.AUTHORIZATION NO: A 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)
P
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
C IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUE
RESIDENTIAL SPECIFICATION: BUILDING TYPE _A/ # BEllROOMS #BATHS # OCCUPANTS 2GARBAGE 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 ROCK DEPTH, LINEAR FTC
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:,i
IMPROVEMENT PERMIT LAYOUT
,
t� fi-'sq-etc .d=. .y...-.:�y..r .i,a.. �"ti.,. ..t';a:'+.L •ry iiia i '+, .,g .l;, 4 j,: x 66,.•'�,..i a.u.. a,A. v
47
DAVIE COUNTY HEALTH DEPARTMENT - -
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION iv-zv"�Q
. &E:,Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
r sewage Treatment and Disp al�Ru/legis X10 NCAC 10A .1934-.19/68);". Permit Number' �
Date /�f ��� NO 4 97
µ. Location /v�'✓%Av,f
r�
0 s �7`rZ I'r;
Subdivision Name Lot No. Seca or Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms No. Baths No. in Family,
Garbage Disposal YES ;❑ NO Specifications for System: ,
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES NO `cf%�V.JF��
Type Water Supply_—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
�_ } R �.
' r
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8M-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. t
Fi al Installation Diagram: System In to ✓ /
! r .
Gi
.,�.'.
,... ...._ Mme+:. - - -
9
Certificate of Completion Date l%Y/
*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.
-,
1. Permit F
2. Address
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department QR 1
Environmental Health Section D
P. O. Box 665 R�
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
,auested Business Phone
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Converitional-26- Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a� If house or mobile home, state size of ome and number of rooms.
House Dimensions f
Bed Rooms Bath Rooms_[_ Den w/Closet
b) If Business, Industry or Other, State: Number of pe
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of w7 ter -using fixtures
commodes
lavatory
dishwasher
served
urinals garbage disposal
showers washing machine
sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ; gc4c 2
b) Land area designated to buildin 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 i correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Name_
Address
1C
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
A SOIL/SITE EVALUATION
FAr.TnRS
ARFA 1 AREA 9
Date
Lot Size
AREA 3 AREA A
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
40
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
SS
S
S
PS
PS
PS
U
U
U
U
i) Soil Drainage: InternalS
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
PS
U
U
U
U
I) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i-
i) Site Classification
,
U—UNSUITABLE S—SUITABLE PS—_Provisionally Suitable
Recommendations/Comments: 0'�Z
Described by �r �� Title' Date
SITE DIAGRAM
UCMD (6-82)