441 Madison Road Lot 7AUUTHGRVATION N r(}j 5` DAVIE COUNTY HEALTH DEPARTMENT
��. Environmental Health Section PROPERTY INFORMATION
Petinittee s . P.O. Box 848 l
Named Mocicsville; NC 27028 Subdivision Name: iUe�A�i aoX
's Phone #: 704-634-8760 "
Dtrecuonstopr'opertyi./d/il/�Sr,i/yi� Section d Lot: r%
AUTHORIZATION FOR Jt ,
,rtl WASTEWATER Ta ice PIN:# r/"' toll*
SYSTEM CONSTRUCTION
r Roadame: `i�AA I Sb/✓ Zip: vg
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health' Section prior
to issuance of any Buildingpermits: This Form/Authorization Number should be presented to the Davie County Building Inspections
Officee when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A; Wastewater Systems, Section 1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
. ENVIRONMENTAL HEALTH 9fECIALIST,, DATE ISSUED
' .-.- J• �y ..K99r '.,�'Y �l N qV,r�. Y w-•L'�it �i�i ii�.r P'14 1a +.wy'-. 'r �4'.4rP,. �aw.y .1. ., .. .�:. �v..,. ..
V y 'y`'a' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
P� tees
NSubdivision Name.
Directions to propertywry% ,i r. '.. I 'Wle i ROVEMENr Section: ' Lot: r7
%PT RM1T Tax Office PIN:#hm
Road Name: MgE)136 jip:42'769g
s ,
"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
cens"ctionfinstallation of a system or the issuance of a building permit
(Incompliance 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
d rLu .` � .tea �C�`+ ,r31 , j //• li7 PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
-RESIDENTIAL SPECIFICATION: BUILDING TYPE, # BEDROOMS ,:,� # BATHS —.V--# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _, # PEOPLEISHIFr' # SEATS _:INDUSTRIAL WASTE: Yes or No '
LOT SIZEi1v� TYPE WATER SUPPL,�Y^''� O DESIGN WASTEWATER FLOW (GPD) y?p�/N,,EW SITE� �REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE -/GAL. PUMP TANK - GAL.- .TRENCH WIDTH �>>��ROCK DEPTH /-:2 LINEAR Fr.
w OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: -
**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.
DCHD 05196 (Revised)
" . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE
' L T 8c ATV -
Davie County Health Department D
Environmental Health Section
P.O. Box 848 JUL 1997 i.
Mocksville, NC 27028 TV
y (704) 634-8760 ENVIRONMENfRLHERIli
1 I 1 I)AVIE CO rM
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
�®®
1. Name to be Billed 'Q,1`L 5 Co Wer V- LLO l i O ti %%W�� 11' r Contact Person —1Z Cub 1 + A
Mailing Address 06 How e Cw/ Home Phone
City/State/zip R 0 C Q S- 1 U r ' NC , I tq M Business Phone
2. Name on Permit/ATC if Different than Above'
i
Mailing Address City/StateMp
I
3. Application For:], Site Evaluation [ ] Improvement Permit & ATC [ ] Both
4. System to Serve:. ] House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other !
5. If Residence: # People � # Bedrooms �a # Bathrooira/ �] Dishwasher [ ] Garbage Disposal
] 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
If yes, what type?.
Y No
EITHER A PLAT OR SITE. PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***AXUAqCOF THE PROPERTY MUST BE
SUBMITTED WITH W APPLICATION.
>c'- o
co
Property Dimensions: WRITE DIRECTIONS (from ocksville) TO PROPERTY:
Tax Office PIN: # -'1
Property Address: Road Name .h `A 1
city/zip 0C V'56 t LSF V C/
If in Subdivision.provide information, as follows':
Name:
Section: Lot#: Lof ;
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 A1tthorized
Representative of the 'Davie County Health Department to enter upon above described property located in Davie County and owned
Buz1 '+Afc L �
by � to conduct al res�ti�-,-procedure cessaryrto determine the site suitability:
DAT l SIGNATURE l
Revised DCHD (06-96) - -
THIS AREA, MAY BE USED FOR. DRAWING YOUR: SITE PLAN:- - - - - -
i
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Lot # 7
'vnw 'LO -/ S� �
0 "'/i�
Names O
Date
6
PS
U
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U
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2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
Address o -
Lot Size
eW20-0
S
PS
FACTORS - I AREA 1 ARFA 9 ARFA A AREA A
1j Topography/ Landscape Position
S
PS
h
6
PS
U
S
PS
U
S
PS
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
Q5)
S
S
PS
S
PS
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
A
S
PS
S
PS
U
U
U
1) Soil Depth (inches)
®
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
PS
S
PS
U
U
External
S
S
S
PS
S
PS
U
U
i) Restrictive Horizons
Available Space
S
S
pS
PS
U
U
1) Other (Specify)
S
PS
U
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PS
U
S
PS
U
S
PS
U
1) Site Classification
. U—UNSUITABLE S—SUITABLE E,& --Provisionally Suitable
Recommendations/Comments: s %) 2R4'
Described by,?). Title Date - -c6 l
SITE DIAGRAM
IdZ0
DCHD (6.82)
Lo I/ ''