1454 Peoples Creek Rd_ _ . -. -
'•"_NOTE'" ThicAdthorirnion for Wnsl�W ater Svvcm G m.witiati MUST REISSUIiI) M'The,D;nic County"Emm
iranem THeulthScnion prior
u ivvunnce Of ua, Building'1'xnnn ThinPomUAknhori /at ion Nuntllm shot, d hi presented niihx Dasie CimiitVBuilding Inspections
-Officewhenupph'l ... Rwlding Bcrmit,
(In compliance witWAniclel If (if G.Sl•Chapter d 30A. Waf awSS'nelin. Section 190OS Wage Traafracta and �Disptn:J SYsteiorl
/-'u—" r - INVALID FOR APERIOI)OF FIVE YEARS.
DA 1-11 ISSUED --� -
RESIDENTIAL'SPECIFICATION: BUILDING TYPE H ,-BEDROOMS 5 #BATHS 'Z .e OCCUPANTS GARBAGE OISPOSAL:.Yeeor No
COMMERCIAL SPECIFICATION:, FACILITY TYPE_. p PEOPLE pPF.OPLFlSH1ET_ x SEATS_ INDUSTRIAL'WASTE:Yeear Na
LOTSIZE - TYPE WATER' SUPPLY - ` DESIGN WASTEWATER FLOW(GPD) JLd NEWSITE REPAIR SITE'
SYSTEMSPECIFICATIONS: TANK'SIZF. GAL. PUMPTANK GAL. TRENCH:WIDTH -'G ROCKDEPFH 11 LINEARFT. 12!9
REQUIRED. SITS MODIFICATIONS/CONDITIONS:
r -
L lays'
1 E'
1. 1
r
GU�L 11 eT tS�I'�IJ
5(17ii(.'ILn'1iL C�L7CI
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ku o 11 1).1-e 5 .
l�plft Creta P
ilOR FINAL INSPECTION OPTmS SYSTEM PLEAS]. CALL BLTWEEN 8:30-9:30A.WONTHE DAY OF INSTALLATION.TCLP.PHONE. IS (3361751-87W,
IMTG 'fin L n�
SYSTEMINSTALLED.SY: "Wl'"IYl/M6 _
,ai-rcmoNt$ bu\I nAnJo,\vc
i _ ibv6, t
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r
r 2, 6xs�.�xy
NO.
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,�—
permit6ii
arllJrDAVIE.COUNTY
HEALTH'DEPARTNIENT
�
Nrve: hnvironmentaHealthSeclion
PROPERTY,
INFORMATIO<{!YGI
�o, na.Iu,r
848
DirectionsL'.O.'Rox
to propehYo- - _
Al tcAville. NC 27028
SuhJieieion:N'ame:-
i•' <VI C.2r OfUlllr5 (;1'u v ILLI
Phone P:, 336-751-8760
�- -
$eLllOn:
9:01:
—
L I IUJL �IY
Vl11NOR1%SIION FOR
Cltw[ 71111")
WASTEWATER -
I nOlficelPINIH
Nl N7 NY CONST RUcrli)�N.
1454. ..
AUTHORIZATION^NO 002938 A.
RoaJNaine 1(DP�;r
II
Lt4Ill&ip:7AtL-
_ _ . -. -
'•"_NOTE'" ThicAdthorirnion for Wnsl�W ater Svvcm G m.witiati MUST REISSUIiI) M'The,D;nic County"Emm
iranem THeulthScnion prior
u ivvunnce Of ua, Building'1'xnnn ThinPomUAknhori /at ion Nuntllm shot, d hi presented niihx Dasie CimiitVBuilding Inspections
-Officewhenupph'l ... Rwlding Bcrmit,
(In compliance witWAniclel If (if G.Sl•Chapter d 30A. Waf awSS'nelin. Section 190OS Wage Traafracta and �Disptn:J SYsteiorl
/-'u—" r - INVALID FOR APERIOI)OF FIVE YEARS.
DA 1-11 ISSUED --� -
RESIDENTIAL'SPECIFICATION: BUILDING TYPE H ,-BEDROOMS 5 #BATHS 'Z .e OCCUPANTS GARBAGE OISPOSAL:.Yeeor No
COMMERCIAL SPECIFICATION:, FACILITY TYPE_. p PEOPLE pPF.OPLFlSH1ET_ x SEATS_ INDUSTRIAL'WASTE:Yeear Na
LOTSIZE - TYPE WATER' SUPPLY - ` DESIGN WASTEWATER FLOW(GPD) JLd NEWSITE REPAIR SITE'
SYSTEMSPECIFICATIONS: TANK'SIZF. GAL. PUMPTANK GAL. TRENCH:WIDTH -'G ROCKDEPFH 11 LINEARFT. 12!9
REQUIRED. SITS MODIFICATIONS/CONDITIONS:
r -
L lays'
1 E'
1. 1
r
GU�L 11 eT tS�I'�IJ
5(17ii(.'ILn'1iL C�L7CI
Yerobve C'Y'S'I''T J
lull 1'vN vplvc
Iuv('shy(-6"Dc" L)')
ku o 11 1).1-e 5 .
l�plft Creta P
ilOR FINAL INSPECTION OPTmS SYSTEM PLEAS]. CALL BLTWEEN 8:30-9:30A.WONTHE DAY OF INSTALLATION.TCLP.PHONE. IS (3361751-87W,
IMTG 'fin L n�
SYSTEMINSTALLED.SY: "Wl'"IYl/M6 _
,ai-rcmoNt$ bu\I nAnJo,\vc
i _ ibv6, t
F
r
r 2, 6xs�.�xy
NO.
U'+
"'NOTE"' Thls Aulfionvaliondirr N'asLLw'at r Ss.'t •in"Glinamclinrr MlJST BI 'ISSUBU br Ihe'D:ivie COnlit, Iinvironmcnl I HuJIFScelion prior
to nuance nl any Building P nnnv This FoHn/AUIhUri,whiv Nunlhershould be presented m the Davie County Bi ndIng'Inspections
Office when applving for- Pecans.
.
(In compliance With'AniJe I LufG:S, Chaprr130A:' WuN1 , gle'Sveleme ScnioR.l9(q Sce age+Cmulntem anJ'Dispxual Sv,aanal
r
�J "'NO'1'ICF 'I HIS AM HORI/\T'ION FOR WASTEWATER CONSTRUCTION
3 I.S.\',\LIDFON \I'ERIODOf FI\E1'F IRS:
RESIDENTIAL SPECIFICATION: BUILDING TYPE H
-BEDROOMS
ii BATHS'. Z
'0 OCCUPANTS_
GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITYTYPE_
NPEOPLE
aPEOPLFJSHIFT
-SEATS
�Perjnitlees .y
DAVIE'COUISTY HFA LTH DEPARTM ENT
TG��
[ , I ..n.rn..
I
LOTSIZE TYPE WATER SUPPLY
Fnmmnmental Health Section
PROPERTY INFORMATION/(
`� REPAIRSITE
T
P.O. Box 848
)1
I D incl ons to PmPe�Y
NC 27028
Subdivision Name
Phone ne 9: 336-751-8760
- -
Seumn:
Lot:
VLTIIORIZAIIONFOR
In., Office PIN.O.
SYSTEM CONST RUCI'IIN
Z AUTHORIZATION=NO:
f�
Road�Noad,N ;Bnr: .. ,
. • • ! i./Zip: .) •
"'NOTE"' Thls Aulfionvaliondirr N'asLLw'at r Ss.'t •in"Glinamclinrr MlJST BI 'ISSUBU br Ihe'D:ivie COnlit, Iinvironmcnl I HuJIFScelion prior
to nuance nl any Building P nnnv This FoHn/AUIhUri,whiv Nunlhershould be presented m the Davie County Bi ndIng'Inspections
Office when applving for- Pecans.
.
(In compliance With'AniJe I LufG:S, Chaprr130A:' WuN1 , gle'Sveleme ScnioR.l9(q Sce age+Cmulntem anJ'Dispxual Sv,aanal
r
�J "'NO'1'ICF 'I HIS AM HORI/\T'ION FOR WASTEWATER CONSTRUCTION
3 I.S.\',\LIDFON \I'ERIODOf FI\E1'F IRS:
RESIDENTIAL SPECIFICATION: BUILDING TYPE H
-BEDROOMS
ii BATHS'. Z
'0 OCCUPANTS_
GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITYTYPE_
NPEOPLE
aPEOPLFJSHIFT
-SEATS
INDUSTRIALWASTE:Yr,.,Na
[ , I ..n.rn..
I
LOTSIZE TYPE WATER SUPPLY
:DESIGN WASTEWATER FLOW(OPD)
..'�'O NEWSITE'
`� REPAIRSITE
1
SYSTEMSPECIFICATIONS: TANKSIZE -GAL. ^PUMPTANK_GAL.
TRENCHWIDTH �� ROCKDEPTH 1( iLINEARFT. ILY
REQUIRED SITE MODIRCATIONSICONDITIONS
IMPROVEMENT PERMITLAYOUT
j
.I'Ir.ITL .IC'l
P!'I'I'IUVf (YI'"I
f�,Jl loo, vokc
IL
,I'ur (L ri h r
Ip oII h;I(g.
E �I FOR FINAL INSPLCHON OF THIS SYSTEM PLGSE CALL BETWELN n:309:30A.1. ON THE DAYOF,IN'STALCATION:TE EPHONBnIS036)751-low. I
II /
OPERATION,PERMITMPS-
SYSTEM INSTALLED BY: F
.�"r<mu�rd bulllunJrdvc
3gY I
- Ibws s
ON NO, OPERATION PERMITBY: fA'1 WOIM1\I �y\ (Tk
B
_DATE: 'I ALI0
•S BEEN INSTALLED IN COMPLIANCE
BUT SHALL IN NO W AY,BE TAKEN AS A
FROM—MUSTIN CONStRUCTION CQ FAX NO.':7669403 Apr. 14 2009 09:16AM P2
p
fal,
-DO�L�A��, [70 '
YAO Davie County He,-dih De
IEnvironmSec
ev,-cd HaJth 6or-
P, Ci. "Box 84
HowiLd Sime!
0 Cr.-j"ier 09--t0-06
a IN-locksvi"e, NC 27028
llici;u:
�
ON-STTF WASTENVATLR CERTIFf CAT] ON Olt -4D"E,',I,LINC-.
(CheukOuc) Replacement Remodelingy, R'econneffit)ln
&AR�)Nzme:
'433HTIF. A0drngs:
et>
k Cvm-tZA
u
5C 7 541
L LA_tCr-Tr 1.�
Lco-1— Eca 4!116-0 Mr. r 202F�— r--MX� U IUM- '60v .599E
Ymperly Addre=_�-�-
/0%9(3 V"JDs
T-5ig—(E-ZOW &C
]Please Fill In The Ful1owbig Information About The EUSTING Facility:
Of NW ---.5
The FuMty CuTrently Vacant? Yol. C Zr—ym, ur-Fnr How Loop?....
r if Y.S.
Please .Fill In The FOUDwing Information Abo ut The 2VE, rVk'JeWry:
Type offacility: ; MD M ��S— N'.3mbn
Requested P>': JDarr
Approved ilkDisapproved D
For tnIATonTne.vaI.7.4m!th Office Ll^.,u ':).-v!Y
EN
Ir T. -#-�
E-n-virc,nmemn! Health Specialist Dew
`rhesign-ing ofzhls forts by the Staff Ln no way intendez), nor whould be f2keflas SuM,all-2.
I i.'�uctlo nperly for any glnren pc, -i, U
x -O.T -rie on -5"a WaStt,;,RteT System w. mi pi -L
cludox .1*te6)ejalt'�
�&Li muncy (,der n- i;, A.nount-.S
Cash C
FYIr4 Poofyt "�-novillq A PJAI( Ws;dt -�o ni,41ce- Red doom
i
ermittee' �% DAVIE COUNTY HEALTH DEPARTMENT a
`( Q(nt
�ame. % Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 �j 1
Directions toert : ro l / ✓
P P Y �' �� P� Mocksville, NC 27028 Subdivision Name:
�/Lt �?00C Phone #: 336-751-8760
ice( L" Section: Lot:
AUTHORIZATION NO: 0 0 2 6*}' � A
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION lySybales C�reek� -
Road Name: N Zip: 2,706&
**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 bavie 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)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS c-?— # 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 ly DESIGN WASTEWATER FLOW (GPD)?iNEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r
i
A
11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT
SYSTEM INSTALLED BY:
6Krba'
AUTHORIZATION NO. OPERATION 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 02102 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME L2z4,9,'%1 A4 Chi
PHONE NUMBER
ADDRESS 1 �_I Plx �
SUBDIVISION NAME
D�/llY�,��✓C�`' , ly r LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED %A'Z�'NAME SYSTEM INSTALLED UNDER
TYPE FACILITY /Y 6" P NUMBER BEDROOMS- NUMBER PEOPLE SERVED
TYPE WATER SUPPLY i G SPECIFY PROBLEM OCCURRING
DATE REQUESTED Z INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that i; ers I am responsib or all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGE
Rev. 1193
**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)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPP�� # BEDROOMS -— #BATHS J, l- # 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) tt x rl`d NEW SITE REPAIR SITE �'" "�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH a (r ROCK DEPTH LINEAR FF.,)
OTHER Ae 5 060
eccepted Systems may also be use
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 0
OPERATION PERMIT
I
SYSTEM INSTALLED BY:
t �
r.
A ORIZATION NO. OPERATION PERMIT BY: DATE:
pis—
"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) C .t�- �° °a 3�3 a ,�,L) 0 p i
Perr:Iitteb's'l
DAVIE COUNTY HEALTH DEPARTMENT
�/
• Name: �'%`%< </ r-'�+
'r %
Environmental Health Section
PROPERTY INFORMATION
v
P.O. Box 848
- Directions toro ert
P P Y�'
f; ' '' '
Mocksville, NC 27028
Subdivision Name:
Phone #: 336-75-8760
)
�tJ j
r
Section: Lot:
'AUTHORIZATION FOR
tWASTEWATER
r'
Tax Office PIN:# - -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002576 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)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPP�� # BEDROOMS -— #BATHS J, l- # 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) tt x rl`d NEW SITE REPAIR SITE �'" "�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH a (r ROCK DEPTH LINEAR FF.,)
OTHER Ae 5 060
eccepted Systems may also be use
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 0
OPERATION PERMIT
I
SYSTEM INSTALLED BY:
t �
r.
A ORIZATION NO. OPERATION PERMIT BY: DATE:
pis—
"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) C .t�- �° °a 3�3 a ,�,L) 0 p i
`�� ,aPerihceL a DAVIE COUNTYHEALTHDEPARTMENT ,
w' Name: -''+ Environmental Health Section PROPERTY INFORMATION_
P O Box 848 '
,#- ..Directions to pr perry: Mocksville, NC 27028 Subdivision Name:.
_ w�' Phone #: 336-751-8760
s Section:
r y I AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION —
AUTHORIZATION NO: 002576 A Road Name:
Lot:
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)
` ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYP �--/', � # 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) cz_` `/ANEW SITE REPAIR SITE G'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH t ROCK DEPTH rte— LINEAR Fr.,
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
5� f
v
11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT
SYSTEM INSTALLED BY:
/ I N
)
......-�-. r ......-....:A-owe
'S r
�56OPERATIONA ORIZATION NO. PERMIT BY: DATE:
"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.
DCHD 02102 (Revised) _ �% 4 q7'000
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME /� �� PHONE NUMBER
ADDRESS/ �U'fJ/PC C��E'iC ,// SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED -6 ZAME SYSTEM INSTALLED UNDER -S//,.-,'y,:f
TYPE FACILITY A0 / NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY c0 SPECIFY PROBLEM OCCURRING
DATE REQUESTED
NFORMATION TAKEN BY
This is to certify fhat the information provided is correct to the best of my knowledge,
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
responsible for all charges incurred from this application.
Account #: 990003030
Billed To: Gary Lackey
Reference Name:
Proposed Facility Residence
ATC Number: 3884
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5880-80-2242.GL
Subdivision Info:
Location/Address:
Property Size:
12eA—
Peoples Creek Rd. -27006
15 + acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: % Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
F�
le
Septic System Installed By:
Environmental Health Specialist's Signature :�G/ Date: 111/6W ✓
DCHD 05/99 (Revised)
` * t DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section At /1_/6 - y
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003030
Tax PIN/EH #: 5880-80-2242.GL
Billed To: Gary Lackey
Subdivision Info:
eference Name:
Location/Address: Peoples Creek Rd. -27006
roposed Facility Residence
Property Size: 15 + acres
ATC Number: 3884
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type L�9 #People f4 #Bedrooms _� #Baths
Dishwasher: Garbage Disposal: e Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New ❑ Repair ❑
System Specifications: Tank Size,&2_ _ GAL. Pump Tank GAL. Trench Width , �: Rock Depth Linear F
Other:
Required Site Modifications/Conditions:
IM PROVE NI ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
F
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002128 Tax PIN/EH #: 5880-80-2242.GL 2
Billed To: Phase IV Realty Subdivision Info:
Reference Name: Gary Lackey Location/Address: Peoples Creek Rd. -27006
Proposed Facility: Residence Property Size: 15.22 acres Date Evaluated:
Water Supply: On -Site Well Community Public v
Evaluation By: Auger Boring ZPit Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
,
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � / EVALUATION BY: _ �/� - 1/
LONG-TERM ACCEPTANCE RATE: ' ) OT
HE (S)
REMARKS: -'L'J
M
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface.,
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS (provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
ell
,r•.1 APPUCATiON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC !� ,
Davie County Health Department
! Env/ronmenfa/ Heath Sm on
*. P 0. Box 48/210 Hospital Street 0'
,.;. 4
Mo sville, NC 27028
(/J row
51-8760 . �7L- L***IMPORTANT*** THIS AP LIGATION SE PROCESSED UNLESS THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
Name to be Billed i o h4 ni L
Contact Person
/
�
Moiling Address _! {
Some Phone
City/state/ZIP 16&e?lo �; %�2
Business Phone
2.
!tame on Permit/ATC if Different than Above
Mailing Address
City/state/Zip
3.
Application For: 2 Site Evaluation
❑ Improvement Permit/ATC ❑ Both
&
4.
System to service: ❑ Mobile Home
❑ Business ❑ Industry ❑ Other
5.
-If Residence: # People
# Bedrooms
# Bathrooms
�
.0'Dishwasher 0/Garbage Disposal W1N,ash1ng Machin ❑ Basoment/Plumbing
T ❑ Bassmant/No Plumbing
6.
If Business/Industry/other: Specify type
# People
# sinks
# Commodes # showers
# Urinals
# Water Coolers
IF FOODSERVICE: # Seats Estimated Mater Usage (gallons per day)
7.
Type of Mater supply: 13'-Crounty/City
❑ Well
❑ Community
s.
Do you anticipate additions or expansions of the facility this system is intended to serve?
❑ Yes ❑ No
If yes, what type?
'**IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS (from Mocksville) to PROPERTY:
r / t
Tax Office PIN: # � �� � —� ��✓�1 �Z '
Property Address: Road Name `-/' !_6kZ91",�Flll I
City/Zip kplmveg,,71 / 'rafiQ� �Gl 4 L
If in a Subdivision provide information, as follows:. �� �jm�iSu O kI
Name: %� G'O�/ z'ivt' ��Dj ��✓ //.�G
Section: Block: Lot: Date :pertyFlagged: _
This is to certify that the information provided is correct to the hes o my knowledge. I understand that any permit(s)
Issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the Information
submitted in this application is falsified or changed. 1, also, understand that 1 am responsible for all charges Incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie Count! 1 I ii Department .
to enter upon above described property located In Davie County and owned_py
to conduct /all testing procedures as necessary to determine the site sui bility
DATE < T SIGNATURE �
THIS AREA MAY BE USED FORD
G YOUR SITE PLAN (Incl 11 the owing: Existing and proposed
property lines and dimensions, structures, s tbac and septic locations .
,_J
o�
w
4, ,
L-14 3
55)
1496
PP
------------
�to 095
O
\,4096
1066.03
15.2
�45
• `,
(5.03A)
'.
9190
: ' •�` DAVIE COUNTY HEALTH DEPARTMENT
i Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990003030
Billed To: Gary Lackey
Reference Name:
Proposed Facility: .Residence v Property Size:
Water Supply: On -Site Well
PROPERTY INFORMATION
Tax PIN/EH #: 5880-80-2242 GL.B
Subdivision Info:
Location/Address: Peoples Creek Rd. -27006
see map Date Evaluated:
Community
Public
Evaluation By: Auger Boring Pit Cut
C.,
FACTORS 1 2 3 4 5 6 7
Landscape position L 11--
Slo e %
HORIZON I DEPTH W
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: �
REMARKS:
EVALUATION BY: i
OTHER(S) PRESENT:
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI Firm VFI - Very firm EFI - Extremely firm
Wet
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS (provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
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