1488 Jericho Church Rd Permittee's ,! DAVIE COUNTY HEALTH DEPARTMENT
Name: /� P.,� ,.y �� mat Environmental Health Section PROPERTY INFORMATION
NJ P.O.Box 848'
)Directions to property,: ocksville,NC 27028 Subdivision Name: h•C' � �•
_1LIr 41—✓ .r' / Phone#: 336-751=8760(,e- � 0 p
Section. J Lor.
AUTHORIZATION FOR
WASTEWATER Tax Office PIN*SYSTEM CONSTRUCTION / �y
AUTHORIZATION NO: 2533 A Rmoi
Road Name: •r' /Zi "' 70�7d
**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)
�* ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f':% ;!}f y $- IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #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)SL NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH /LINEAR FT.e
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"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 S-OTALLATION.TELEPHONE#IS (336)751-8760.
i
OPERATION PERMIT
SYSTEM INSTALLED BY: "el
a l'
r
AUTHORIZATION NO. � OPERATION PERMIT BY: DATE: /7
"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.
ncHn 02oi(Revised)'
P ~ - 17— '�
ermitfee's�` ��'� DAVIE COUNTY HEALTH DEPARTMENT 5
Environmental Health Section PROPERTY INFORMATION
P.O. g 848
a.,..n.„_.t.,�_.-..s.��.�.__.y�_.�� .•gyp,,' t
yuec6ons to property:` 40cksville,N 27028 ------Subdivision-Name;–� a-- •: �:._
/Rot
(� J Phone#: 336-751=8760 `
— / t t k5V# ' I e, A l/ 7, 1�1 0 Section: f Lot: `
AUTHORIZATION FOR
WASTEWATER Office Tax
SYSTEM CONSTRUCTION ax O PIN:#lqw
- -
{ AUTHORIZATION NO: 2533
A Road Name � �j'"f�-' � Q(it"�i �76.28
**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 FornVAuthorization Number should be presented to the Dave 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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIR NMENTAL HEALTH SPECIALIST DATE ISSUED { `
RESIDENTIAL SPECIFICATION:BUILDING TYPE ,�,(/�� #BEDROOMS ` #BATHS `.# CCUPANTS GARBAGE DISPOSAL:Yes or No
i
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
i�
.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 FT
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
- IMPROVEMENT PERMIT LAYOUT
**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 SIUf TALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: �� }
..............
, f
t
AUTHORIZATION NO. '" ,UPERATION PERMIT BY: DATE: �1 /
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
Wean oaioi(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND''*PERTIFICATE OF COMPLETION
+ 'NOTE: Issued in Compliance with G.S. of'N'drfh Carolina Chapter 130 Article 13c
/`f1 4 ,, 1, .Sew Jre�atmer14Q0 Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date C1 - r, -?.J" '� 3
Location %;
Subdivision Name c, Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths } No. in Family _
Garbage Disposal YES ❑ NO [:I. Specifications for System: 1 c,0, ;1 �-
Auto Dish Washer YES ❑ NO p
Auto Wash Machine YES NO '❑ �
Type Water Supply 0,n,
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
i-EN --"
f7i
Improvements permit by
6!
`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 comple ion—TUl6lSTione umber: 704-634-5985.
Final Installation Diagram: System Installed b -,V, J , C,-,;;
t /60(1
q
g i 11o�.S�
Certificate of Completion / �� /1� -nDate
*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 r •
DAVIE COUNTY HEALTH DEPARTMENT i A 3 �s
Environmental Health Section .JtAlr- 11ci��
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �1A��� �u.l�ler3 Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils -- PS PS
U U U U
4) Soil Depth (inches) S S S S
<— PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS
U U
External S S S S
ez:TS-> � PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS 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 %. o,,k Title � � �' Date 9-I0
SITE DIAGRAM
r
las
x
X
il►�
DCHD(6-82)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Q`7 �� V -7/ z
• APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) L1
NAME_ ISL-L f "" _ PHONE NUMBER
ADDRESS <1 ` Cir lfd• SUBDIVISION NAME
S 11-L LOT #
DIRECTIONS TO SITE / tsh
DATE SYSTEM INSTALLED g s NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY C L -�SPECIFY PROBLEM OCCURRING
DATE REQUESTED / INFORMATION TAKEN BY , U
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.1199