247 Papoose Trail Permittee's J f VIE C0UNTV;;HEALTH DEPARTMENT
Narre:, „/elf c''. Environmental Health Section PROPERTY INFORMATION
wig P.O. Box 848 .� F
Directions to property: Mocosville,NC 27028 Subdivision Name:
Phone# 336-751-8760
,' ! Section: Lot:_.. z
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# -
' SYSTEM CONSTRUCTION
2246
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 I 1 of G.S.Chapter 130A,`Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�1
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS I#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
�/R
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH� f� LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITI NS:
IMPROVEMENT PERMIT LAYOUT
CPO
Y
**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: ��� ��• 'fir
` � ... .
AUTHORIZATION NO. � PERATION 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)
GC/C CSG r� �
g'F:30
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETrO.N/j %J f
*NOTE: Issued in Compliance with G.S. of North .Carolina Chapter 130 Article 13c ! �,
- Se's r atmen and Disposal Rules (10 NCAC 10A .1934-.196 ) P@I'Ifll , Numbers Name Dated' - y k 3 C1 r,
Location r-�' _
Subdivision Name Lot No. 13 Sec. or Block No.
Lot Size — House --'"Mobile Home _ Business Speculation
No. Bedrooms _ No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑f Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES . NO''❑
Type Water Supply
"This permit Void if sewage syste described bela .�s:r�ot installed within� onths from date of issue. --
A . '
Improvements permit by —
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 day of completion. Telephone Number: 70.4-634-5985.
Final Installation Diagram: System Installed by
i .'
o_
J°
2 4
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 systemrill furiction
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
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.
Home Phone q9y-fid.9/
1. Permit Requested By Business Phone
2. Address y31
3. Property Owner if Different than Above 2;!P�
Address A , AZZZ'.�. 919— X it a
4. Permit To: a) Install ✓Alter Repair
b) Privy ✓Conventional Other Type
Ground Absorption
c) Sub-Division, -74�OSec. Lot No.1-
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 2-
6.
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 28 X W)
Bed Rooms -9 Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: umber of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher / sinks
8. a) Type water supply: Publics Private Community
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.
rL2%L�
Dat 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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Ax :
le
3
I
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name l/'`� 2'� Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
A�> PS PS
U !� U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) S � PS PS
U U U
3) Soil Structure (12-36 in.) S� S S
Clayey Soils PS PS PS
U U
4) Soil Depth (inches) S S S
�l� PS PS
U U/ U U
5) Soil Drainage: Internal S S
pS PPS PS
j%
6t� (US--!-- U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons _
7) Available SpaceCFS
S S
PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title ���-� Date
SITE DIAGRAM
DCHD(6-82)