312 Ralph Rd _ ___ _ _ _ __
• ' OF;ERATI4N PERMIT or ice se n v
Davie Caunty Health Department *CDP Fife Number �1897.14•1
,.._ . _ _ .
, . ,
� 210 Hospital Street
� P.O,Box 848�� � County ID.Numbe�;.
� � �
�'°•^�''� Mocksv�lle NC� �7028, Evaluated„Fo.r. NE�(11
Phane:336-753-6780 Fax:336-753-1680 Township:
Applicant: Tony Gobble Property owner. Tony Gobble
Adaress: 1655 tVC Hwy 801 N Address: 1655 NC Hwy 801 N
��Y� Mocksville ��Y- Mocksville
State2ip: NC 2702$ State2ip: NC 27028
Phbne#: (336)99$-6488 Phone#: (�3fi)998-6488
Pro ert Location 8 Site Information
Address/Road#: Subdivisan: Phase: Lot:
Ralph Road
Macksville NC 27028 Directions
sc�ucture: SINGLE FAMILY hwy 64 East, left on Cornatzer Rd. Road on Right
near Church nearest to Milling Rd
#of 8edrooms:
#of People: 2
`Water Supply: NEW WELL
'IP issued by. ztao-N�uons,Roeerc 'System Clessific�tan/0escription:
TYPE II A.CONV SYSTEM(SiNGLE-FAMILY OR 480 GPD OR C�E85) '
*CA issued by: 2140•Nations,Robert Saprolite System? QYes (�No
Design Fiow: a q � �OistributionType: GRAVITY-SERIAL Pump Req ired?
QYes (�jNo
Soil Applicatan Rate: � , a *Pre Treatment:
Drain fietd
N�ritic�tian Fietd Z a � � S4��� "System Type; �NFILTRAT�R QUICK4 STANDARD
No. Drain Lines 4 instaper. Sherman Dunn
Totai Trench length: 3 � 6 �� Certification#:
Trench S acin , g Inches O.C.
p g �,� — _,_. �Feet O.C. 'EH S: 2140-Nations,Robert
Trench'Vlfidth: _ 3 inches
- gF�c oet�: e � laa / a � �. s
� �
Aggregate Depth: inches
Minimum Trench Depth: 3 �
_ Inches
� k �7 a'.
Minimum Soil Cover. a a �,qPa�y����a��g` � � � �W
� Inches_ �� � � ��`°
MaximumTrenchDepth:'3 6 �'�ApprovedCCl Dtsapproved -�
Inches
x�, ���
_ � -�;,.a .� s ��
� .
Maximum Soil Cover: a 4 Inches
_ _
_ _
__
�o�Fi�e Number 139714 - '! �o�nty ID Number: ,
Se tic Tank �
Manufacturer. shoaf Lat. �
Long:
&TB. 760 _ '
Gail�ns: ��
Instaaer. Sherman Dunn
Date: � g / 1 6 / a 0 1 4 Certification#;
'EH S: 2144-Nations,Robert
*Filter Brand: F'OLYLOKPL-122 With�,peAdapter
sT Martcer. ❑ Yes � No �ate: . 0 3 / a 4 / � � 1 5
ReinforcedTank: ❑ Ye� � NO � `� �p������e��� `� � �
� ��sae 7ank: O Yes Cl N Q � �������pprov+�d❑ �3isapprcrve'd
"�r `� ���, �.. q�;`'
Pump T�nk
Manufacturer. lnstaUer.
PT: Certification#:
Gallons: - *EHS:
Date: / � Date: � f
RisecSealed ❑ YQS ❑ No
RisecH�ght. O Yes ❑ No iMin.6 in.} - Appraveost�tus � �r,�`
ReinforcedTank: O Yes ❑ N� �s�p $qpprovedCl Dis�ppra�r+etl
� � 1 PieceTar�k: ❑ Yes ❑ No �� ���� .�� �r ��. ��� �_��
Supply Line
Pi�e Sizg: inch diameter insta�er.
Pi�e Lengfh: feet CertificaGon#:
*Schedule: *EN S:
�r�ssure Rated p Yes ❑ NO Date: � �
Ap�roved frttings ❑ Ye5 ❑ NO � `�m �i '°: aPPt�yval�f�tus �W �� ���
`CI �►pproved� "�7isap�rrnred` `
, = ; e
_� .� �,. �.��,� __..,� -_�«...:�.� � r.,. ���
Pum p Type. tn�ta�er.
Dasing Volume: - ,��� �ertification#:
�
Or�w Down: Inches f��S'
*Chaat: � �
Date:
Vatves Accessibie ❑ YeS ❑ N+D �
Flow Adjustment Valve ❑ y�5 ❑ NO
Check-vatve ❑ Y�S ❑ N 0 �� � ;� =s-Appraei;Stetus'; T``'� � ,�
; � < , °'
Pvc unions O Yes: ❑ No, �� CI �pPpraveci� C�isappraved �'
Vent Hole ❑ 'Yes ❑ No p� � .��� �.r�� ° ��,�s ,�����.,s
Anti-siphon Hole ❑ Yes ❑ NO
_ _ _
CDP�i�e Number 139714 - 1 County ID Number:
Electric E ut ment
NEMA dX Box or Equivalent ❑ Y�S ❑ NO lnstaGer.
Box 12 inches Above Grade ❑ Ygg ❑ �p
CertificaGon#:
8ox Adj.To Pump Tank Q Yes ❑ NO
Conduit Sealed ❑ Yes ❑ No 'EHS:
Pump ManuatlyOperable ❑ Yes ❑ No
=Activation Method: Date: � �
r A�provB!Status � � ,
Alarm Auai6�e � Yes O No � - =�
�C]' Approved❑ Disapprov�etl' �
AIaRn visibie ❑ Ye$ ❑ N o '` " � 1�"
2140-Nations,Robert
"�p�ration Permit completed by�
Authorized State Ag ' Date of Issue: � 3 � a 4 � � � 1 5
OwneNAppticant Signature�
This system has been installsd in compliance w�h appticable NC General Statutes:Articte 11,Ghapter 130A, Rules t'or
Sewage Treatment and Oisposa1,15A NCAC 18A.1900 et. Seq.�and ap conditions of the Improvement PeRnit and
Construction Authorization.This prope�ty is se�ved by.a TYpE 11 A. $gyyagg g�p�IC SyStefll.
Rute.996t requires thet a Type ���A septic system meet the following criteria:
M�imum System Review ByThe Locat Health Department: WA
Management Entity: OWNER
Manimum System InspectionMlaintenance Frequency ByCertified Operator.
wa
Reporting Frequency 8y Certified Operator.WA
Rule.1961 �equires that a Type IV and V septic,systems desgned fora home/business owner must mai�tain a valid contract
w�h a public management entity w�h a certified operatoror a private certified operato�forthe tife of the septic system.
Rule.1961 requires that Type VI septic systems designed for a home/business owner must matntain a valid cantract with a
public management entitywith a ce�tified operator iorthe life of the septic system.
Rule.i96t,(2)(e)requires a contract shaU be executed between the system awner and a management entRyprior ta the
issuance of an;Operation�'srmit fo�a`system required to be maintained by a pubfic or private menagement ent�y, untess the
systsm ownerand certified operatorare the same: The contracf shall require specific requvements formaintenaace aad
operafion, responsib�lities of the owner and systems oper�tor,proVisions that the cont�act shall be in.effect fo�as bng as#he
sys#em is in use,and otherrequirements for the,cantinued proper pertormance of the system. R shatt elsb be a cond�ti�n of
the�Operation Permit that subsequent owners`af the systems execute such a contract.
UHand Drawing 4lmport Drawing -.
**Site PIan/Drawing attached.** t �X�-,�
_ _ _ _ _ _ _ __
OPERATI�DN PERMIT
�avie County Heattti Department COP File Number: 13�971�- 1 .
21�Hospitai Streef
P.o.Boxsas +�ounty File Numher:
nnoc�.s�jne �vc 2�a�s �►ate: / /
Qinch
Drawing Drawing Type: 4peration Permit Scale: . pN�c�c .ft.
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. ° CONSTRUCTION EIVIAILED D S ; . . : For:Office Use Oniv `
AUTHORIZATION �Ih?,I�� ' � *CDP Fite Num6er 139714�'1 '
°��' Davie Coun Health De art►�$�'� �
� •�� � �� � � �
,� ''� tY p - County ID Number �
� 210 Hospitai Street �In i le0( ou�N�� ' `� � ` �
� 1r`� Evaluated For: NEW
�.�,�„o. P.O. Box 848 ` ,
�Township _, .
. __ . . . _ _ __ . ... ; . . : .�.. . . -
Mocksville NC 27028 PERh1IT VAUD UNTIL:
Phone:336-753-6780 Fax:336-753-1684 0 � / 1 � � a 0 1 9
Applicant: Tony Gobbie Property Owner. Tony Gobble
Address: 1655 NC Hv►ry 801 N Address: 1655 NC Hwy 801 N �
C�y: Macksvilie City: Mocksviile
State2ip: NC 27028 State2ip: NC 27028 .
Phone#: �336)998-6488 Phone#: (336)998-6488
Propertv Location 8 Site Information
AddresslRoad #: ' Subdivisan: Phase: Lot:
Raiph Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY hWY 64 East, left on Comatzer Rd. Raad on Right near
Church nearest to Milling Rd
#af Bedrooms:
#of Peopie: 2
*Water Supply: NEW WELL
Svstem Speciflcations
Minimum Trench Depth: a 4
Site Classificatan: Pro�sionat�ysuicabie , Inches
Minimum Soil Cover.
Saprolite System? QYes �No 1 a Inches
Design Flow: a 4 � Maximum Trench Depth: 3 6 Inches
Soil Applicatan Rate: � . a MaximUm Soit Cover: a 4 Inches '
"System Classification/Description: � 'DistributionType: GRAVITY-SERIAL
TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) SeptiC Tank:
1 0 0 9 Gatlons
"Proposed System: 25%t�EDUCTION 1-Piece: QYes QNo
Pump Required: QYes �No QMay Be Required
N�rification Field 1 a 0 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: QYes QNo
TotalTrench Length: 3 � � � GPM—vs— ft. TDH
Tr�ench Spacing: _ 9 Qlnches O.C. Oosin Volume: _ Gallons
QFeet O.C. 9
'french Width: Inches
— 3 �Feet Grease Trap: Gallons
Aggregate Depth:
inches pre-Treatment: ONSF OTS-I C�TS-II
Septic Tank Installer G rade Level Required: �I �I) �11I �IV
� '
CDP File Number 139714 - 1 County ID Number:
� ❑ Open Pump System Sheet
Repair System Required:�YeS ONO ONo, but has Available Space
epair Svstem
7nench Spacing: �Inches O.C.
_ *Site Classification: ProvisionanySuicable __ __--_ _ _ _ _ _ _ ____9 - Feet O.C. __ _. _
Trench Width: Inches
Design Flow: .a 4 � � � — 3 �Feet
Aggregate Depth:
Soit Applicatan Rate: � a inches
� Minimum Trench Oepth: a 4
'System Classification/Description:. _ Inches
TYPE II a CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) �inimum Soil Cover. � a Inches
Maximum Tnench Depth: 3 6
*Prpposed System: 25%REDUCTtON Inches
Mazimum Soi1 Cover: a 4
NRrification Field 1 a � g Inches
Sq. ft.
No. Drain Lines "Distnbution Type: GRAVITY-SERIAL
3
Tota(Trench Length: 3 � g ft Pump Required: QYes �No �May Be Required
Pre-Treatment: ONSF OTS-1 ' OTS-II
"Site Modifcations
Wo grading or construction acfivity is allowed in areas designated for system and repair without approval of Heatth Depa�tment. ��
7:
'Permit Conditions
The issuance ofthis permit bythe Heatth Department in no wayguarantees the issuance of other pennits.The permit holder
is responsible for checking with appropriate goveming bodies in meeting their requirements. ;;
2(
This AuthaizaUon for Wastewater Systen Constructfon sha11 bevalid tor a person equal to the period of�alidfty of the ImprovemeM Pertnf�not
- to exceed tive years,and may be(ssued atthe sametime the Improvement Pertnit fswed(NCGS 130A-336(bj}It the Installation has not been
compteted during the perlod of wlidity of the CortsVuclion Pemnit,the ftiTormation submiued in theappllcation for a pertnit ar Constructlon
Authorization Is found to have been lncors�ect,talsitied or changed,or the site is al�ered,the pertnit o�Constructbn Authorizatlon shall become
invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling fhe syster►shall be responslble for assuring compliance
with the laws,rules,and permit oondlLions regarding system locatton,insiallation,operatlon,maintenance,moni�odng,reporting and repalr
' (1938(b)).
ApplicanULega1 Reps.Signatur�e Required? OYes ONO
ApplicanULegal Reps. Signature' Date: � �
'ISSUed By: 2�40-Nations,Robert Date of Issue: � � � 1 � � a 0 1 4
Authorized State Agent: �i�i��� .�—�-• Malfunction Lo9 OYes
�Hand Drawing Olmport Drawing
**Site PIan/Drawing attached.**
n.,....n ..s�
. � CONSTRUCTION AUTHORIZATION
• oavie Counry Hea�th�ePartment CDP File Numbe�: 139714 - 1
210 Hospitai Street
P.O.Box848 County File Number:
Mocksvilie NC 27028 Date: 0 � � 1 � / a 0 1 4
__.__ ___ _ _. _
_ _ ---- __ __ _ ____
_
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . . . OB�ock ; . .ft.
QN/A
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APPL�ATION FOR SITE EVALUATION/IIVIPROVEMENT PERMIT & �TC
.�Q� Davie County Environmental Health Deea; 7 A,j�
��' P.O.Box 848/210 Hospital Street ���
'�►� Jl � Mocksville,NC 27028 ; �b :
� , (336)753-6780/Fax(336 7�3-1G80
App ' ation For: 0 Site Evaluation/Improvement Permit uthorization To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION � 2N� 33(� �2� 7
Name �� Contact Person ��(p �g-�Q�$Q
Address Home Phone
City/State/ZIP � �/' ` Business Phone 33(0-1Q�,i�(��
Email �
Name on Permit/ATC if Different than Above �
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facilit Corners Fla ed �
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) .
(Permit is.v '�r 60 mon hs with site plan,no expiration with complete plat.)
Owner's Name D Phone Number
Owner's Address City/State/Zip �
Property Address City �
Lot Size ��� $I� , Tax PIN#
SubdiVision Name(if ap licable) Section/Lot#
Directions To Site: (� /�=�-- [�rn�-k- Pr
-- -R�--� :- --------���- �
_ .� �--
_._ _
.�----- _, _ _-
Specify Problem'Occuning: -
� ��A 11 b�'-o r� o� � �b le cc P . _
��- �;,�...�� _ � �
y �
�_. ,.____. -
_-- ..._�_ a -
_ � _� _— . _
-�__ - _..�- _
IF RESIDENCE FILL OUT THE BOX BELOW �
#People O� � � / #Bedrooms #Bathrooms�_ Garden Tub/Whirlpool OYes o
Basement: ❑Yes [9D�6 Basement Plumbing: �Yes+8��
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative OAlternative ❑Other
__ . __._. _.___ ____---�___.._.----------._ _ ._-------- __..____ ___.__.
Water Supply Type: ❑ County/City Water �1Vew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes,what type? �
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s)or�TC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use
changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules.. I understand that I am responsible for the proper identification and labeling of property lines and corners and
locating and flagging or st king the house/facility location,proposed well location and the location of any other amenities.
i
� �'l Site Revisit Charge
Property wner's or owner's legal representative signature
Date(s):
/v f� � Client Notification Date:
Dat — EHS: ' .
Sign given ❑Yes ❑No � Account# I��� I
Revised 11/06 Invoice# G�v 7 v'l ,
,
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Scale:l"= 1210 A ril 13,1998 3:27 PM
. . �y � ,� �N4'�' � _ fl � [� pd �
- ;• "%� ,� � � � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE &ATC
• z' � Davie County Health Department � t 6 �
� � Environmental Health Section
�'�' � P.O.Box 848 �,L,
�v Mocksville,NC 27028 �""`� �:'���f�''';��
(704)634-8760 � �
�
� ****IlVIPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED����',� yl•t c,1�n•��L.,
1. Name to be Billed 1 D���4.P�1 l`��Y]b I'� Contact Person �w� 1���������'�.
Mailing Address H l��O[ �� ���' �o tV�� Home Phone �f� 6 Lo�� o
c�
. City/State/Zip �oC��Sv���2 1 vC o��c�c3-� Business Phone �f�s---�f a�7
2. Name on PermidATC if Different than Above
Mailing Address City/State/Zip
3. Application For: i�' Site Evaluation 0 Im rovement Permit&ATC ❑ Both
4. System to Serve: O House �'Mobile Home ❑ Bu ' ess ❑ u ❑ Other
�
5. If Residence: # People �_ # B drooms _�_ # Bathrooms _�_
0 Dishwasher ❑ Garbage Disposal �" Washing Machine ❑ Baseme mbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: ❑ County/City ell ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes,what type?
�
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A.PLAT OF THE PROPERTY MUST BE
I/}��os SUBMITTED WITH THIS APPLICATION. '
Property Dimensions: �I�� x IQ�_�;X yY�K �(3� � WRITE DIRECTIONS(from
� Mocksville)TO PROPERTY:
Tax Office PIN: # �7��j' - - S � �Y I fl
� t
Property Address: Road Name � �
� C o!1 A ¢ �
City/Zip OL � 0�7 l�c7 �
I � � � �� �.•
1
If in Subdivision provide information,as follows: i N �
t
Name: �
1
Section: Lot #: �
1
1
This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)issued hereafter �
aze 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.I,also,understand that I am responsible for all charges incuned from this application.I,hereby,give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by�1��'�L V Dv''��5 to conduct all testing procedures
as necessary to deternune the site suitability.
� S /� SIGNATURE � �
DATE �� "
�
Revised DCHD(06-96) � �j',(fj
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Scale:t' = 1210 A ril 13,1998 3:27 PM
. � � : ' ' �avie County�Cealth �epart:ment
� ;,�MB�R: ga ancl�ome.�CeaCth��enc�
,.w pNo����N 22� �g �nvironmental�f'eaCth Section
EFF�G.�'.33 '1G.Q760 P.O.BOXC RIEF#09-40-�6 STREET
';�'� V
MocKSVILLE,N.C.27028
Pr+oNe:(704)634-8760
• May 14, 1998
Tony Allen Gobble
1655 Hwy. 801H.
Mocksville, HC 27028
Re: Site Evaluation/Ralph Road
Tax PIN: �15769-43-7504
Dear Client(s) :
As requested, a representative from this office visited the aforementioned
site on May 13, 1998. Based upon the information provided on the application
for a site evaluation and after the evaluation vas completed, the site was
found to be provisionally suitable for the installation of a reodified,
oversized on-site sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely�
j
Jeff G. e champ. R.S.
Environmental Health Section
JB/trd
Enclosure(s?
. ,�;� ' • .
, , . DAVIE COUNTY HEALTH DEPARTMENT
� � � � Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME �O�� ���/� DATE EVALUATED_ S��3 l�l�
PROPOSED FACILITY /��• �t� PROPERTY SIZE �€5
SUBDIVISION ROAD NAME ��- Q�
Water Supply: On-Site Well -� Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 . 2 3 4 5 6 7
Landsca e osition C. L
Slo e%
HORIZON I DEPTH �
Texture rou .SGL C,l. �
Consistence i ss S : ; 5 �
Structure (< j L
Mineralo � 2` I "S�
HORIZON II DEPTH - Z(o
Texture rou G � G
Consistence � �;
Structure
Mineralo ' �
HORIZON III DEPT'H -�f -t./
Texture rou ; L+
Consistence �� F; S
Structure �L ,4 1G
Mineralo � �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION ,S
LONG-TERM ACCEPTANCE RATE n y O�Z
SITE CLASSIFICATION: �S EVALUATION BY: ��-� ��1�7
LONG-TERM ACCEPTANCE RATE: �'^� OTHER(S)PRESENT: ��17- 1�i0��^�. �'�'�
Tt—�L�..�s�
REMARKS:
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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineralo�v
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-gaUday/ft2
DCHD(01-90)
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AUTHORIZATION NO: � 1�4� 3 DAVIE COUNTY HEALTH DEPARTMENT
• � � Environmental Health Section PROPERTY INFORMATION
P�rmittee's r � l P.O.Box 848 �
Name: ��� C��Lt�s Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property:,���t0�'L l� Section: Lot:
AUTHORIZATION FOR
� SYSTEM CO STRUCTION Tax Office PIN:#j7fva- �3 -��
� — T Road Name: '�AL.�!} �7 Zip:_�
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Forrn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance w' Article 110 .S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
� **•NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� J IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON HEALTH PE I DATE ISS ED
RFSIDENTIAL SPECIFICAT'ION:BUII.DING TYPE #BEDROOMS #BATHS 'Z- #OCCUPANTS_�GARBAGE DISPOSAL:Yes or o
; .
COMMERCIAL SPECIFICATION: FACII.,TTY TYPE � - #PEOPLE �#PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
�Q yi �'J�
LOT SIZE1�"'TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD),(� NEW SITE �REPAIR STTE
' ' �� /I i
SYSTEM SPECIFICATIONS: TANK SIZ.E �� GAL. PUMP TANK GAL. TRENCH WIDTH_� ROCK DEP'I'H �Z LINEAR FT. ��'�
I
. . o�R ` i ���TPa�t7Tt o•� �.-,-yC
REQL3II2EDSTTEMODIFICATIONS/CONDTTIONS: ff�[��l�L �� C7�`�1�
IMPROVEMENT PERMIT LAYOUT ���ti.3 ��x�t��
• /t�0� . Q`�ll� .0 .
/CL� �
�
, 1 /c�v
_ ' ly
� '
�
� . �
. . �
' - �:. ��� � �
NEW PHONE NUMBER: `
EFFECTEVE MARCH 22, 1998 �/
336 751-8760 T'o f.2�`�K �
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECITON OF THIS SYSTEM �
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATTON.TELEPHONE#IS(704)634-8760.
OPERATION PERMTf
. SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERIvtIT BY: DATE:
"`*THE ISSUANCE OF THIS OPERATION PERMTT 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 WII.L FUNCITON SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96(Revised)
, � . �
' y • M
{ CEI�D�PLICATION FOR PRIVATE WELL PERMIT
�' . Davie County Environmental Health
,���..� C� P.O.Box 848/210 Hospital Street
Dar„_� Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
***IMPORTANT*** -
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name ��{'y� �Ot�Y��� Contact Person��U �.TD{���G D�'��
Address ��_r,� W V �,p� �(. Home Phone_3� - qCi�- (�y g�
City/State/ZIP�(��C�V�1��.L�, a,7p�g Business Phone �31�- -1�2_LI(oS9
Name on Permit if Different than Above �'�i,F - �2S _c.�r.�31
Mailing Address City/State/Zip
PROPERTI'INFORMATION *Date House/Facility Corners Flagged
7- 0
NOTE: A survey�lat,or site plan must accompany this application. Included: � Site Plan ❑Plat(to scale)
Owner's Name � � �p Phone Number
Owner's Address�� {-�t� Q,p► h(. City/State/Zip
Property Address City
Lot Size Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
DEVELOPMENT 1NF0 ION
Permit Type: New Well Well Repair Well Abandonment Other(specify)
Facility Type: Residential Food Service Church Commercial Other
Are There Any Septic Systems Cunently On The Site? YES NO
Do You Intend To Install A New Septic System On This Site? YES NO
TERMS AND CONDITIONS:
This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines
with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic
system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying
and marking the property lines and comers. The applicant is responsible for making the site accessible.
By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
. determine the best location for a well.
� �lvt_ 7 �G� ,
Signed � � Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Account#
Invoice#