186 Linda Lane Lot 10Z✓Xo
AUTHORIZATION NO:` "1 31 4 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Perm rttee's . P.O. Box 848 J
Name. Mocksville, NC 27028. ' Subdivision Name: f 1�16Z
Phone #: 704-634-8760
Directions to property f Section. i Lot: !�
AUTHORIZATION FOR
p
T"V'jj r t 4 ..WASTEWATER ' - Tax Office PIN:# S%$y-._�
SYSTEM CONSTRUCTION /
61-t C eX OLsSAc Road Name: Lr.liL2^ (4-jz- Zip: Z`7D2.
**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/Authorizadon Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliancewip Article 1.1 of G.S. Chapter 130A, Wastewater Systems,; Section .1900 Sewage Treatment and Disposal Systems)
�r /
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION .
IS VALE) FOR A PERIOD OF FIVE YEARS..,
F)WIPOMMLT
EARS.-
EIROFIMLT
H SP IA T .DATE IS UED q'-
`T7'
DAVIE COUNTY HEALTH DEPARTMENT
`art; IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION V
Peimittee's
Name: h J 1
Direc£i6ns to property:
,11C1..-0 tt-rYt t
SA[
Subdivision Name: r 3tf'� �/ is 1-Lrm r I.4,n: e,
Section: % Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name: L i&k7A e4-%: Zip: Z'7vZ
**NOTE** This Improvement Pemut DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system An II
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.wlth 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
-i b
4I zu PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMt; VT i• , qfEALTH SPPCIALkST DATE IS UED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE F)JSC, # BEDROOMS --LL— # BATHS --"') # OCCUPANTS 12 GARBAGE DISPOSAL Ye or No,
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE # PEOPLEISHIFT � #SEATS INDUSTRIALS WASTE: Yes or No
LOT SIZE . 7� 40e WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)zu � y� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE jf))DGAL.PUMP TANK GAL. TRENCH WIDTH 3o ROCK DEPTH Z LINEAR FT.
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OTHER 3 �� I01tZ✓-�!N "
REQUIRED SITE MODIFICATIONS/CONDITIONS: _ It3STAL.t-0a C.Dr)TD�JK , Ke: I, t DFF FFO-- y
IMPROVEMENT PERMIT LAYOUT -
1 /x3�"x/z fly F eo rrt
/001 � _ ;A q
*L
T
Npt AOtx
75 ��
FP�JT ARDx
'fS
**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
r -
AUTHORIZATION NO. M1 Y OPERATION PERMIT
I
**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 930A, 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)
SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department //%%
Environmental Health Section 61Zt-
P.O. Box 848 7-o 14101-1 1'&Mocksville, NC 27028
(704) 634-8760
APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �//7�Q z • /,%/ S/he,
Mailing Address X
City/StateMp Pif/I jA N.' �%� • %O/ %
2. Name on Permit/ATC if Different than Above
Mailing Address
Contact Person '19h2te—
Home Phone 9/0 '940 9-
Business Phone 9/o -7111
City/StatefZip
3. Application For: (] Site Evaluation D4 Improvement Permit & ATC ( )Both
4. System to Serve: House [ ] Mobile Home [ j Business [ ] Industry [ ] Other
5. If Residence: # People --6 # Bedrooms # Bathrooms _ [A Dishwasher [h] Garbage Disposal
W Washing Machine [d Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify
# Showers # Urinals # Water Coolers -
# People #Sinks # Commodes
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: A County/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes W No
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***WPQW OF THE PROPERTY MUST BE
A� SUBMITTED WITH THIS APPLICATION.
Property Dimensions: See- �T�� /�� - 1 WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # -f -7.rr- /,�� i d 41 ^ -2r' 4,05A ee1.4[. G/. Ra(' OA.rr
Property Address: Roadl�ame,/�/�� Z,9,4/e— - avwn Load- -". -&
City/Zip A, e, S-✓r1fc �7d a -f
If in Subdivision provide information, as follows:
Name: /i9A66";hq 792C4. _)0%" -
Section:
%"Section: / Lot#: Aq r pw 9
This is to certify that the information provided is correct to the best of 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. I, also, understand that I am responsible for all charges incurred 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.
DATE 5 �^ S- fir
Revised DCHD (06-96)
THIS Al,A .`1AJ BE USED FOR DRAWING YOUR SITE PLAN:
procedures as necessary to determine the site suitability.
o f /.,a�' `� :s ,�/a.[ , oto �•acP,.e.d. ! W g �
X
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION / Q7
Date(��/� /
Lot Size— X j y A ys xVI"
to
APPA 1 ARFA 9 AREA 3 AocA A
1) Topography/ Landscape Position
S C
PS(
U
S
7 PS
� U
S
PS
U
S
PS
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
Tl
S
PS
U
S
PS
U
3) Soil Structure (12-36 in.)
Clayey Soils
U
U
S
PS
U
S
PS
U
t) Soil Depth (inches)
'-�j
TTTJJJ
S
PS
U
S
PS
U
i) Soil Drainage: Internal
5,.�
/¢WSJ
U
S
PS
U
S
PS
U
External
S
PS
S
PS
i) Restrictive Horizons
Available Space
U
S
S
PS
U
S
PS
U
i) Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
'77
—7317—
U—UNSUITABLE S—SUITABLE P_ --Provisionally Suitable
Recommendations / Comments:
Described by _
SITE DIAGRAM
UCHD (6-e2)
Title -5�,4/t/ Date al/7lrt
,Za7/D
' MRS. CHARLES MISE
I 91-584
S29.19'11' E
ElPf ARM*
DEED BOOK I pAGL4 Lr
3,978. �ElP 4 � J 009 acres
�' LOT 9
b
/ y ec3' �,1p2
m Z 4T EIP
NTP
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THIS WILL CERnFY 1 AT THE SUBIECT PROPERIY ( ) IS / (X IS NOT LOCATED IN A SPECUL FLOOD HAVM AREA
AS DETERMINED BY THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT.
OF
.� KENNETH L FOSTER CERTIFY THATUM
THIS MAP WAS DRAWN UNDER MY SUPERVISION FROM AN BRYAN 'MSE
ACTUAL FIELD SURVEY MADE UNDER MY SUPERVISION ON
MARCH 2 19 98 ; I FURTHER CERTIFY THAT
ACCORDING TO SAID FIELD SURVEY, THE PROPERTY LINES FOSTER-BULLARD ASSOCIATES, PA
AND LOCATION OF ALL STRUCTURES ARE ACCURATELY PLANNERS—SURVEYORS
SHOWN HEREON." _ app sus am Pm. - sun le
,..... jy.,� CAROLINA HOME PLACE
G\ST,y9 MAP OR
PMT OF 9 &
LOT M, 10 sEc. ONE P.B. 5 PO, 196
SEAL
L•2552 0 91 Pc. 584 TwsP. MOCKSVILLE
7c� �SU�`�� GJ`, TAX LOT TAX BLX. MAP
kIIYLEEP.I.N. DAME COUNTY. N.C.
SCALE:
1"_r5. JNOB 1708-98A