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427 Comanche Dr �y�ro 5 f�)� �'�^f'� F .J L,. , h '�' .. h _ . a . .. ., . ._ve.,17 ha ':'j,.' t � t..•._ �. Peroittee sEvc ,_ DAVIE COUNTY HEALTH.DEPARTMENT &P7Y�/2MA�OA,yob Environmental Health Section PRION P.O. Box 848` ` Directions to property: + 10 �� Mocksville,NC 27028 Subdivision Name: /Aw7L1N ��-1•-� Phone#:336-751-8760 —it Cf_� Section: Lot:- AUTHORIZATION ot:AUTHORIZATION FOR WASTEWATER SYSTEM Tax Office PIN:#�_- - F,M CONSTRUCTION � AUTHORIZATION NO. 2336 A Road Name:7� , **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 applyi g for Building Permits. .On,cpmpliapce ith'Article 1 I of G.S. ap 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ! ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. -- ENV,IRON AL HEALTH SPECIA ST DAR ISS ED RESIDENTIAL SPECIFICATION:BUILDING TYPE--10Q& #'BEDROOMS #BATHS 13 #OCCUPANTS / GARBAGE DISPOSAL:Ye or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE �C' TYPE WATER SUPPLY (��_ DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. .TRENCH WIDTH 3LJ ROCK DEPTH t 2 LINEAR FT. OTHER ' �I /►y f4 REQUIRED SITE MODIFICATIONS/CONDITIONS:. 14501-t- `f7/VI 7P02 IMPROVEMENT PERMIT LAYOUT►K12 �, , AN b **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 S\ SYSTEM INSTALLED BY: y sny ^� A JL jqAUTHORIZATION NO. OPERATION PERMIT BY: DATE: v 1 ` 0 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA T STEM 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) j� 9' 5 �- L-=ll�Pa�l� Q h� /kSley — �6L�• ' _ S'�n� �'D jet 74 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NA C I2� PHONE NUMBER ADDRESS Ca ry'k4n C-ke-4Z-. D& SUBDIVISION NAME::t;aI A.) . LOT # 1 a DIRECTIONS TO SITES / " C DATE SYSTEM INSTALLEDC� O NAME SYSTEM INSTALLED UNDER A/ie1 " / TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING e c L( '1 -e -e ou o' , e.J DATE REQUESTED y INFORMATION TAKEN BY 1 Q This is to car*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.tro3 !�TtA/6 3AIebb —a 60 /x-� CA)03q DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ; i, *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 Namei �/��fJP! / `�� ./ve ` �"�^Dd4+r1��-Date NO Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms - No. Baths No. in Family — Garbage Disposal YES p NO p" Specifications for System: e Auto Dish Washer YES NO p �Qa �Z--D Auto Wash Machine YES NO fl moi' Type Water Supply 'This permit Void if sewage system described below is not installed within 36 months from date of issue. i .i Improvements permit by _�—t//' �l '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. Tele ho umber: 704-634-5985. n Final Installation Diagram: Sy a Installed by i� • i %I Certificate of Completion -- DateO� "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. , 5 "yi-"t:♦ -..ni Y i ':=J Y.fc"i y y y.,. .v'.Ia " '_+,. ['-;c: •y. .,,j L_a. _ .. - - 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 NameEA Pr�� f ,., �/Q!nF-�Date � / NO _ T 552 Location Subdivision Name - // - Lot No. Sec. or Block No. Lot Size S = f House Mobile Home _ Business Speculation No. Bedrooms No. Baths' No. in Family Garbage Disposal YES ❑ NO _ Specifications for System: Auto Dish Washer YES NO ❑ ,� <;�X Auto Wash Machine YES NO' ❑ ��`�� "a�%�� Type Water Supply 14c, *This permit Void if sewage system described below is not installed within 36 months from date of issue. - ;i i 4 Improvements permit by #--uL 4Z *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. Tele ho umber: 704-634-5985. Final Installation Diagram: Sy a Installed by L� Certificate of Completion Date ea *The signing of this certificate shall indicate that the system described above has been installed in compliance with i 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. Y ; 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION / Name Df�S� Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS PS U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS U U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS PS PS `tom U U 4) Soil Depth (inches) S S PS PS LU U U 5) Soil Drainage: Internal S S S PS PS U U Externals S S � PS PS C—!PS `tT U U 6) Restrictive Horizons 7) Available SpaceQS 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 J. , U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described byj�� r� Title Date �? SITE DIAGRAM DCHD(6-82) t, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section 7 P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 01112 -` 1 � 3 1. Permit Requested By� 1-D c ky hL_De12TY Business Phone 2. Address -D.IC 7 ti � Js��« �� L. 2 7o a 4 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: Housed Mobile Home Business Industry Other b) Number of people Z- 6. a1 If house or mobile home, state size of home and number of rooms. House Dimensionse i Bed Rooms Bath RoomsP Y, 7 3 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 3 urinals garbage disposal lavatory showers washing machine dishwasher f sinks 8. a) Type water supply: Public—Private Community b) Has the water supply system been approved? Yesy No 9. a) Property Dimensions 22n X 5:s o b) Land area designated to building site 70 t,� R_D r-0 5-11 c) Sewage Disposal Contractor Sc LF 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? ),a This is to certify that the information is correct to the beof my kno ledge. Date 7 ner§ignature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 7- 7/ DCHD(6-82)