129 Alamosa Drive Lot 10vx0
DAVIE COUNTY HEALTH DEPARTMENT
t IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME Alpo t4 4 �S PROPERTY ADDRESS II �(� 71 i�S Q. b r . DATE �rJ
LOCATION ��i9%%lp�I�llr
SUBDIVISION NAME LOT NUMBER r— __SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE AAl/ # BEDROOMS # BATHS .9- # OCCUPANTS -4V GARBAGE DISPOSAL: Yes/Xoe)
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE Z&)'&-?/ TYPE WATER SUPPLY e�a DESIGN WASTEWATER FLOW (GPD) -�� NEW SITE L," REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE AM) GAL. PUMP TANK GAL. TRENCH WIDTH _fZf ROCK DEPTH , � LINEAR FT. S7J
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY
u
r -
AUTHORIZATION NO. _ OPERATION PERMIT BY�G�I/ DATE 1�
4vo?
**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 10/95
.}. .l"S:d-„y,✓`4 J.Yn.�Yrw. s� "w�i .=.t..�iH �4.. '.i'P'S'0„a1'r:+�' Y.�ti.:- y,J•,{;;ti�.,�.;L� i�.: ty e'.} r..� } ,
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
✓ic6 ,
(Issued in compliance with Article 11 of
B.S._,,Chapter 130A Wastewater Systems)
***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.***
NRME DATE �— �/'9rS � AUTHORIZATION MUTER
N_ r J090
NAME ON IMPROVEMENT PERMIT (If different than above) 'Y rti
SITE LOCATION
CONKNTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT -WASTEWATER SYSTEM
\� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PIE 0 V
Davie County Health Department
Environmental Health Section
P. O. Box 665 APR 0 ( .
Mocksville, NC 27028
i
1. Application/Permit R quested By ��l `� e Z' an�
Mailing Address 6 /-:A ax it Home Phone
�i J, I- N. e, Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House 2-1' obile Home n ❑ ((P,,lace of Public Assembly
El Business ❑ Industry ❑ Other BL6 Unknownb f BLcG-tiF
II r
5. If house, mobile home: Subdivision f� A �� N 7A Section& m S Lot # /b $'D
No. of People `T
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions X G�
6. If business, Industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
❑ Basement/Plumbing
❑ Basement/No Plumbing
2 -Washing Machine
CR'6shwasher
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: Q-<ubiic ❑ Private ❑ Community
8. Property Dimensions /DO X LE D � Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? ❑ Yes No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: ItF
Alamo
This Is to certify that the information provided is correct to!Kbt of my
Incurred from this application.
0 ;.-
DATE
SIGNATURE
I am responsible for all charges
CONSENT EM aU EVALUATION IQ 9E DONE .ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 QM the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
1 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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE
DCHD (1193)
SIGNATURE
i DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
�i!
Date��
S
S
Address
PS
Lot Size
1�'/S d
FACTORS AREA 1 ARFA 9 ARFA 3 ARFA A
1) Topography/ Landscape Position
S
S
S
dD
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
�
PS
PS
PS
U
U
U
U
t) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
.�
') Available Space
S
S
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE /PS Provisionally Suitable
Recommendations/ Comments: m
Described by-/3�Title Date
SITE DIAGRAM
CON
DCHD (8-82)