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AUTHORIZATION NO: 17 2 5,4DAVIE COUNTY HEALTH DEPARTMENT y �
j7-�
Environmental Health Section PROPERTY INFORMATION
Permittee's j�` } P.O. Box 848 //�// k
Name: �"— f% r �/i'"G( t'' Mocksville, NC 27028 Subdivision Name:
��,. C� Phone # 336-751-8760
Directions to property: / f ' Section: � Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION —
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 I of G.S. Chapter.130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
1
L ✓ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HFA LT SPECIALIST DATE ISSUED
5 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's l � //
Name: �' '� / ,.-1 r' ,' Subdivision Name:or
G' //�
Directions to property: �:. Yi` �'�'%-rr/i Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
Road Name: Zip:
**NOTE** This Improvement Pen -nit DOES NOT authorize the construction or installation of a 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE _/:20- # 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) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH : ROCK DEPTH / S� LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
tAFPROVED EFFLU :�IFILTER* *RISER( IF 611 BELOW FINISHED GRADE
-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 (704) 634-8760.
XXXIt3tXXX?C
OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. 029 AOPERATION PERMIT BY: DATE: � D
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDI S OV INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREA E ND�DISPOS�ALSYS ABUT ALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
ti '` . "'` ! _,s DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMIT PROPERTY INFORMATION
S
Permittee's /
Name: �' s' C ,�' Subdivision Name:
Directions to property: �' CM ' i' '• - 'i` Section: Lot:
IMPROVEMENT
PERMIT
' Tax Office PIN:#
Road Name: Zip:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a 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 pen -nit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE #BEDROOMS # BATHS , # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE:: YesorNo
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) r NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.' �
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT K '
-xF;Pr' VED I FFLL` 4ILTE1,N- *RIGEl i IF 6" SE1 01,31 FIVIISHED GWADE-x-
.4
"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 (704) 634-8760.
XXXXHXXXX
f—ASE971%1 —R-6
OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. —1'1_ A OPERATION PERMIT BY:. 'r "` DATE: 5 D
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDI ST ED SOV S BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREA E AND DISPOSAL SYSBUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
,AUTI-IOkl:ZA_TIO& NO: Q 9 2 9 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permrtter's/7 P.O. Box 848
Name: r' C." rnfl' Mocksville, NC 27028 Subdivision Name:
j Phone #: 704-634-8760
Directions to property: u"ryALK--U 1 V
Section: /r Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION 1 !!"
Road Name: k/41 �� l.� Lff� F S ip r •.• r f�i1 [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 applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
1 / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
1p;�r'/ �J. i!-�c'1�� ,✓ 1. 7 - IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HE_ A ' TH SPECIALIST DATE ISSUED
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME ;"'f'Z�ec- C PHONE NUMBER
ADDRESS ��L� U l`CY D��s �` SUBDIVISION NAME I/ 4 (ICIOee-
f S
12 700 LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALL/LED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 73"e, NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY [ d , SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
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. 1/93
o��a9
Auf -* //6'9 �u-w- 1.376
J
AVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Per
Name: 1 `` ,�i.
Directions to property:
IMPROVEMENT
PERMIT
Subdivision Name:�?r,'.!I,;
T
Section: Lot:
Tax Office PIN:# ff f
Road Naa me: Va # f f i i f %r fw �ilp:t' `?
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a 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 I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
FLANS UIX TkIE INTENDED USE UftANCiE. YUUK WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUEDSYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
- INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 4/— # BATHS —Z # OCCUPANTS _^7 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE - # PEOPLE # PEOPLEISHIFT jj # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY el . DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE l/
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANKK GAL. TRENCH WIDTH , S (� ROCK DEPTH �� LINEAR FT. r %r'i�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
.a
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 OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. ���2 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 05/96 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
'* •� k> ' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pertfiittec'sk
Dame
Directions to property: : ;:: a i%
IMPROVEMENT
PERMIT
Subdivision Name:�� tfr1 iti�<-
Section: Lot: !
Tax Office PIN:# -
Road Na fine:�r
**NOTE** This Improvement Permit DOES NOT authorize the constriction or installation of a 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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �. # BEDROOMS # BATHS # OCCUPANTS —7 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY rl DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE !/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH .. -7K ' ROCK DEPTH Z L LINEAR FT. -.2`. _ 1 /V)
OTHERk,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r4..
L? `mss
i 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 (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLI
i
y `l
t ,r�
AUTHORIZATION NO. (/ t -'''OPERATION PERMIT BY: +iw f 4 DATE: _,�A 4 7
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYST.tMS' , BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
r DAVIE. COUNTY HEALTH DEPARTMENT' - • s.
i4 ,
+.�• i IMPROVEMENTS PERMIT 'AND CERTIFICATE 'OF COMPLETION
*,NOTE! Issued ,in Compliance with G.S. of.-North. Carolina Chapter 130 Article 13c 4 .
'--Sewage4Treatment and Disposal Rules; (10 NCAC 10A .1934-11968) Permit Number
Name . y 7 ,� i �.� Date , lAillTN2 . 4080
LocationIt
-- II
Subdivision Name ��> o`er%v/�'� Lot No. Sec..or Block No:
Lot Size House _ Mobile Home — .' II4 Business _ Speculation 2
No. Bedrooms_ No. Baths__ No. in; Family'f`_ II
Garbage Disposal YES p NO II
I Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine, YES NO
Type .Water Supply
.. This permit Void if "Sew;ge system' described below Js, not installed within 36.,months from date of issue. '
- •4' f].- / U — C 7 fie• !,!'/ �:7R s5tl
SI i�lC� /0 .,f 7 Z uta ray
' - - (�1� ,. . . . • Sr7�74:/ Sob
—?.
Improvements_per 'it by
-*Contact a representative' of the Davie County Health Department for final inspection of this system .between .8:30'7
.'9:3b: A.M: or 1:0071:30 P.M. on day of completion. Telephone Number: 704-634-5985.
I
Final Installation Diagram's, System Installed by fl
• d.ir � �i s f. 'f '. /f I'll
. J !,, J , • • ,` SII ,
It
7::
1�
Certificate of• Completion' • +� ' -Date ' 6/-// J/
'The signing.of this certificate':shall indicate that the system described above'has,be' en'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..
• ^" DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION ,✓
Name— ,A Date
Address Lot Size
FAr:Tr1RC AREA 1 ARFA 9 ARFA 3 ARFA A
Topography/ Landscape Position
S
�,–�
(P
S
PS
S
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
U
S
PS
U
S
PS
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
U
S
PS
U
S
PS
U
)Soil Depth (inches)
OU
PS
S
PS
S
PS
U
U
U
Soil Drainage: Internal
S
�%
&
S
PS
S
PS
U
U
U
U
External
S
`�
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
P
S
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
UY
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title Date
F,
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME gLw-i4 G n !'Ol' _ PHONE NUMBER
ADDRESS /�S '�� 1��9�1 .Q SUBDIVISION NAME
SUBDIVISION LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY