157 Ginny Lane Lot 5DAVIE COUNTY HEALTH DEPARTMENT'
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in, Compliance with G.S. of North Carolina Chapter 130 Article 13c
S�ewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name 1— \�`\L A" Ve!Q5 �y,�� 'QJCS Date 1 - ��i !r ,? rG A 4
Location
Lot Size House Mobile Home
No. Bedrooms 3 No. Baths No. in Family.
Garbage Disposal, YES p NO %
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO L]
Type Water Supply � " , •
No.
Business
Sec. or Block No.
Speculation I�
S ecifications or System:
i
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
ME
Improvements permit by
A
mo►
*Contact a representative of the Davie County Health Department for final inspection of this system between 830-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:. 704-634-5985.,
Final Installation
Certificate of Completion i, " - Date
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit F
2. Address
3. Property Owner if Different than Above
Address
n
Home Phone q! f'_5_O b 2
Business Phone ' 99,K-5-6,672-
4.
,K-fit;2-
4. Permit To: a) Instal Alter_ Repair—
b) Privy— Conventional& Other Type—
Ground Absorption
c) Sub-Division-5NJAQ9LZ Sec. —I Lot No.. 5--
5. System used to serve what type facility: Housed . Mobile Home— Business—
Industry— Other
b)Number of people
6, a) If house or mobile home, state size of home and number of rooms.
House Dimensions 28 k q 4
Bed Rooms_ Bath Rooms 2- Den w/ClosetA10
b) If Business, Industry or Other, State: Number of persons served —
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes 2 urinals o garbage disposal
lavatory 2 showers washing machine
dishwasher l sinks
8. a) Type water supply: Public —X Private Community
b) Has the water supply system been approved? Yes No -
9. a) Property
b) Land area designated to building site tfeONZ�4CET/7105� 4— S LT 01 -c -S
c) Sewage Disposal Contractor dooyA7z&z, 525o?c %*n/K 5-yr-
10.
Vc10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A10
What type?
This is to certify that the information is c rect to t e best of my knowledge.
34,97 �
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD)6-82)
Kl- mn r G -g" tem %V ►✓X14 kf).
Name
Address —
!I
0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date g 2 i
Lot Size
FAr.Tr1RC ARFA 1 AREA 2 AREA 3
AREA A
Topography/ Landscape Position
<!:V>
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
cfr->
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
i) Soil Structure (12-36 in.)
e5ff>
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
Soil Depth (inches)
e:t>
S
S
S
PS
PS
PS.-v>
PS
U
U
U
U
) Soil Drainage: Internal
<fz>
S
S
S
PS
PS
PS
PS
U
U
U
U
External
1-Z:5>
S
S
S
PS
PS
PS
PS
U
U
U
U
I) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
U
U
U
U
S) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
I) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by S)J-- Title
,SITE DIAGRAM
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DCHD (e-82)
7`.06 v
Date ? _ 2 _t I
Permittees;
06 4
DAVIE COUNTY HEALTH DEPARTMENT
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Name: 1 n(
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Environmental Health Section
PROPERTY INFORMATION
to property: ti f
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P.O. Box 848
Mocksville, NC 27028 .
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Subdivision Name: `<(kl �C
(Directions
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Phone #: 336-751-8760
)
Section: Lot:
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AUTHORIZATION FOR
WASTEWATER
WASTEWATER
Tax OM `� S� i (,7 S`
SYSTEM CONSTRUCTION
cc PIN:# - -7T
AUTHORIZATION NO:
003001 A
Road Name: Lam• 7in.'''
I
**NOTE** This Authorization for Wastewater System Cpnstruction MUST BE ISSUED by the Davie County Environmental Health Section prior II
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 l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems),
1 � ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t�)
;•1(�(�1C�1r tkALkJ IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL hEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 1i5C" # BEDROOMS ' # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE II # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE IC( TYPE WATER SUPPLY 6GY79 < DESIGN WASTEWATER FLOW (GPD) 34-r) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK / GAL. TRENCH WIDTH ROCK DEPTH 40— LINEAR FT. -360
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT �( 4I,yQ (( UCr ILL( 'i0 SarClCL, �••��'(«�
/,vecv�cl(i Sr�SI!/�t cJ A.CCdPI(,
o,u' )
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.
OF
NSTALLED BY: 0. -B `' O
pa J
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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 0= (P.A.d)
Permittee s `` DAVIE COUNTY HEALTH DEPARTMENT
Name ' �- ..( `'' f Environmental Health Section PROPERTY INI
P.O. Boz 848
Directions to.property: f Mocksville, NC 27028 Subdivision Name:
MATION,
( P N l Phone #: 336-751-8760 '
Section: Lot:
h . t . ! r AU ON OR '
L C • 1 WASTEWATERax Office PIN:#
1 STEM CONSTRUCTION TOffi—
AUTHORIZATION NO: 003001 ARoad Name: ( ( "
**NOTE** This Authorization for Wastewater System Cgristruction MUST BE ISSUED by the Davie County Environmental Health p!tcdon prior
to issuance of any Building Permits. This FomVAuthorization Number should be presented to the Davie County Building I spections
Office when applying for Building Permits. ✓,_ ;
(In compliance with Article III of G.S. Chapter 130A. Wastewater SystemsjSection. 1900 Sewage Treatment and Disposal Systems){ _
' c
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
'� '>'•'}'.('lf J �!(! ISYALIDFOR APERIOD OFFIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE iii r' N BEDROOMS M BATHS _ 8 OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE 77 PEOPLE/SHIFT H SETS'_ INDUSTRIAL WASTE: Yes or No
LOT SIZE �` C -t TYPE WATER SUPPLY LLLL DESIGN WASTEWATER FLOW (GPD) 5/-( NEWSITE REPAIR SITE Vs.
U
. SYSTEM SPECIFICATIONS: TANK SIZE --Z—GAL. PUMP TANK -/ GAL. TRENCH WIDTH • ROCK DEPTH 4��IL LINEAR FT. } C^O
�^... OTHER .. _
REQUIRED SITE MODIFICATIONS/CONDITIONS:
riIMPROVEMENT PERMIT LAYOUT
I
1ti'!al( riot( Ic cr cl(l Gtr f rI
t ntl
MI ..
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TEELEPHONE N 15 (336) 751-8760.
OPERe�1l'ION-P ' _ G
INSTALLED BY:
X t
0
S
i
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: / J-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.
'.DMD 02102 (Revised).
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
A14K
Ga !leaf!
NAMEL�AfLiiT 4+ PHONE NUMBER q9Y- 71aS'
ADDRESS 177 ry nna lark. SUBDIVISION NAME 7f ntMo�i lt!
LOT #
DIRECTIONS TO SITE ISIk- UFS RWln, 0 0- % GOA^ -Dewe - % 'R. -All, CAt tc
DATE SYSTEM INSTALLED /o -y% NAME SYSTEM INSTALLED UNDER A144had No,
TYPE FACILITY N NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY &Yt - SPECIFY PROBLEM OCCURRING S4we::j4-_ Aura — +».
DATE REQUESTED (- Z S -It) INFORMATION TAKEN BYE
This is to certify, that the information provided is coned to the best of my knowledge, and that I understand I am responsible for all charges incurred from this applioation.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Date
Location
Lot Size' I — House I IX Mobile Home — Business — Speculation ! '/
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES El NO Q specificationsfor System:
Auto Dish Washer YES NO 61 Jtl� box
Aut�, Wash Machine ' YES NO -E] 6
'
Type Water Supply X
o -31
*This permit Void if sewage system described below is not installed within 36 months from date of issue
Improvements permit by
*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 completion. Telephone Number: 704-634-5985.
Final Installation
�P�n,,-A
Certificate of Completion Q'. DateA6 .2
. --*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 betaken as a guarantee that the system will;function
satisfactorily for any.gAnperiod of time.: