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NO: ,0948 DAVIE COUNTY HEALTH DEPARTMENT t
Environmental Health Section PROPERTY IN�Fl�ATIO
P.O. Box' 848 vroN l�'O®
Su bd:.. N
Mocksville, INC 27028tvtston ame.
rC' - Phone#: 704-634-8760
1.Section: / Lot:
AUTHORIZATION FOR c/
WASTEWATER, Tax Office PIN:, �&, /
SYSTEM CONSTRUCTION
Road Name:7V,4A/SD/y
**NOTE** This Authorization for Wastewater System Constriction MUST BE ISSUEd by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Fotm/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,.Seedon ,1400 Sewage Treatment and Disposal Systems)
***NOTICE!**.TTHSAUTHORIZATION FOR WASTEWATER CONSTRUCTION' -.
G` IS VALID FOR A PERIOD OF FIVE YEARS'.
ENVMONMENTALHEALTH SPECIALIST. --: DATE ISSUED
DAVIE COUNTY HEALTH DE$ARTMENT '
' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION y t'
Subdivision Name:
Directions to roPertP:Lte- �14%�• . .Section: / (�
IMPROVEMENT
PERMIT Tax Office PIN:#�
Road Name: 5Al/I �Eip: 70
**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:
(compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f ***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 of No
COMMERCIAL SPECIFICATION: FACILITY TYPE� # PEOPLE _ # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE/4'9040,1 TYPE WATER SUPPLY r /O DESIGN WASTEWATER FLOW (GPD) ��� NEW SITE .e- REPAIR SITE
. SYSTEM SPECIFICATIONS: TANK SIZE�DQGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH _X2 'LINEAR Fr.?Ce
OTHER
. - REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
<f
"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
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20 rd JirJ . Me,
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AUTHORLZATIONNO. OPERATION PERMIT BY. DATE:
v4�3! a) Sg
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THMSYSTEM DESC 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)
APPLICATION FOR SITE EVALUATION/IMPROVEMF*TT nFuit,Hm R. Amr
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS
nn. THE REQUIRED INFORMATION IS PROVIDED. /n�
1. Name to be Billed q R f– l�D � r � (d �' lWontact Person �b ( ~ t-5
Mailing Address o w at/Home Home Phone
City/State/Zip kb6- t.S U U F, NC DOW Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation [ ] Improvement Permit & ATC [ ] Both
4. System to Serve: Q('] House [ ] Mobile Home [ ] Business [ ] Ind�us(tryy [ , Other
5. If Residence: # People ---i— Bedrooms # Bathroom/ �J [YI Dishwasher [ ] Garbage Disposal
Y] Washing Machine [ ] Basement/Plumbing [ ] 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 [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?( ] Yes YNo
If yes, what type?
_ EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** XF9WOFTI1E PROPERTY MUST BE .
y SUBMITTED WITHAPPLICATION.
Property Dimensions: C1 (�' J�� ►k�� WRITE DIRECTIONS (from Mocksville) TO PROPERTY,
Tax Office PIN: ## -rr' /�'/�
Property' Address: Road Name tt t t b fSokl 1 '
City/Zip koc�SUi�(,� 'ISG n 1
If in Subdivision provide information,
as follows:: y
Name: )Iuk) SEA O�V\
Section: Lot#:�n
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 La [ to conduct 41-tesog procedures a ssary to determine the site suitability.
DATE- LW at) - (ql SIGNATURE
Revised DCHD (06-96)
THIS AREA MAY '13E -USED FOR DRAWING YOUR SITE PLAN:
'ermit To a) Install ✓Alter Repair— - ��-n- ' (•O4
b) Privy_ Conventional p Other Type °' k f�A I 4 -�� L �e
Ground 'Absor tion C}��{ (- Off,)
c) Sub-Division ec. - Lot No.�
>y=,tem used to serve what type facil : House_ Mobile Home— Business—
Industry_ Other—
) Number of, people .
If house or. mobile home, tate size of home and number of rooms.
House Dimensions �(AIti
Bed Rooms Bath Rooms Den w/,Closet
l If Business. Industry nr Other- State, Numher of nersons served
Directions to propertyi' j
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
1, ost (�
Date ` ' 13 % 9
Address Lot Size
FACTORS ARFA 1 ARFA 9 ARFA 3 APPA e
1) Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
Loamy, Clayey, (note 2:1 Clay)
(P,S
PS
PS
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
P
PS
PS
U
U
1) Soil Depth (inches)
S
S
S
S(
PS
PS
'C�
1 U
U
i) Soil Drainage: Internal
S
S
S
S
F S
PS
PS
tY
U
U
External
S
S
P
(PSJ
PS
PS
U
U
U
>) Restrictive Horizons
Available Space
S
S
S
P
V
PS
PS
U
U
U
q Other (Specity)
S
S
S
S
P
PS
PS
PS
U
U
U
U
1) Site Classification
(JAS,
D
U—UNSUITABLES—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: -S_ we e 7.6✓�%1461(-6•41 P•042;1— _46et
Described by g •��� C -Title Date
SITE DIAGRAM
-11>a
DCHD (6 82)
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