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144 Casa Bella Drive Lot 15{ 9t �i Y iri 3 +Y_{i-Y ( n:,�ra �,y BW�iva;C.' "B.M.'oJl ,r. b,�m,'�. .k)�.(' J `..,ilj l,Y7v T-'., h',P• ,Y ,J rr,i AUTHORIZATION NO: DAVIE COUNTY H]�ALTH DEPARTMENT .1369 ; . Environmental Health Section PROPERTY INFORMATION Permittee's F o �T� S P.O. Box 848 Name: F Mocksville, NC 27028 , Subdivision Name: �%'A t-k'z� y Phone #: 704-634-8760 Directions to property: 1 jL )�{tayt: `1 o Section: Lot: t �' AUTHORIZATION FOR WASTEWATER Tax Office PIN:# _ SYSTEM CONSTRUCTION tx-t i F' 2, "1� x?'j Ler l oa Cd :>✓,a 1C) L; 'r C'O, - �, LA Road Na e:_�1SA old ' Zip: 'lot **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/Authorization Number should be presented to the Davie County Building Inspections Office when applying for uilding Pernuts. (In compliance with Article 11 of G apter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) f ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR PERIOD OF FIVE YEARS. ' ENVIRONMEN ALR TH SPE I(,IST DAT I SUED � � �'.h''%i�''�(,'S'y..�`c _� .,y �.,''+-r—A";.�.E ;,.s. �...V `''. ;c'Y`-.; ,i.rsg"F' -�>a.-.v�`w• .;•-F''+..�u�,> , � -_ .. ... -„ - a , - , .� ;�! - DAME COUNTY HEALTH DEPARTMENT �`�'5. Q 13 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION ifezmlttee's '`"1' Subdivision Name: r r Directions to property: i r +.)�{( !�- 1 *� r; , ,` Section: i Lot: ". r''� `Il14PROVEMENT� . �A Ze z� a'�:>CnI +�tf'T� �� _. PERMIT ~ �. Tax Office PIN:# jqq r.kJ'Acr,, stt,°�°' Road, �`�-5r1` it d Zip• 2`70t� **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 cons ction/mstallation of 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) a ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER O EI LTH SPECIAI» ST DATE ISSUED SYSTEXCONTRACTOR MUST SEE THIS j?ERMIT BEFORE INSTAI:LING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE tom{ N # BEDROOMS # BATHS G- # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYYPPE� y' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No, LOT SIZE 50 x� TYPE WATER SUPPLY`-�''`� �Y DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ` SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR Fr. OTHER ),)1 5TC,6J l %!D>J—YJ- O REQUIRED SITEMODIFICATIONS/CONDITIONS: 1N%i41.1 OrJ co„)�oJe , /fl 5r+�C �1..%;S V,JpeQ }��0 �16�SP�Ar IMPROVEMENT PERMIT LAYOUT KIST-ys'sc-;w-- CvT OFF i� 4,7 lo? ' l07 ' "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 AUTHORIZATION NO. OPERATION PERMIT BY: SYSTEM INSTALLED BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMrr 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 05/96 (Revised) .+C7'�: w i qy�q �....`�:'�w i�u )1St b:Y: y+. _,•i:.� -.,a'Y•-.tb --ray". --,.2w-i - _. F � _. ,'• -. -..- r- . DAVIE COUNTY HEALTHDEPARTMENT µ- a„ 1.369 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Peranittee,s,-- s - ' Name: -' e.l' ` 7� Subdivision Name: -"br'rec0ons to property: Section: Lot: IMPROVEMENT. t*uf ; PERMIT Tax Office PIN:# t_t f. e^.'/!!�M:)r3 ;n, L.�r~s �.t r ,n`ni���` Road Name. n,1`�1 t^l( Zip: "7 -)o **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 fivm 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE w PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER, ENVIRON1 IENtAL REALTH SPECIALIST DATE ISSUED SYSTEM, CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS _ # BATHS 2— # OCCUPANTS GARBAGE DISPOSAL:'Yes or No - COMMERCIAL? SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No.'. LOT SITYPE WATER SUPPLY�l Y DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ' SYSTEM SPECIFICATIONS: TANK SIZE1�)2a GAL. PUMP TANK GAL.' TRENCH WIDTH at ROCK DEPTH IS LINEAR FT OTHER—L.D1-5112.60-11v-0 p � REQUIRED SITE MODIFICATIONS/CONDITIONS: Itdi?{rt "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: 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 05/96 (Revised) SAN MARCOS DR fit•; 133 7 IiG 13 N O UI ll M .. N : � . 17 0 21 - •• A•� 0 •off " 96\ o� . �! \a 8 3 "All 18 0 20 Aa c� a 15 32 y 50 19 O • ,'i LL �t��;v 9 ♦ r;;r �.r. 4 4 ryti`` �Tr, eT r i �9 tit u# y p+*q y 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 Name A11 �`r Date3377 Location's%i;Zr Subdivision Name ' ` .1�� .� '� Lot No. Sec. or Block No. Lot Size �' "��fC� House Mobile Home Business Speculation No. Bedrooms - No. Baths No. in Family Garbage Disposal YES p NO p-% Specifications for System: Auto Dish Washer YESNO ❑ Auto Wash Machine YES �j NO rl t/ Type Water Supply *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 Diagram: System Installed bye-/4;IZ�1121 i Certificate of Completion /rG� 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. 4 Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date g/l Lot Size �S-OAlt&2) FAr.TORC ARFA I ARFA 2 AREA 3 AREA 4 1) Topography/ Landscape Position S <i97 S PS S PS S PS U U U U ?) Soil Texture (12-36 in.) Sandy, S�i-. S S Loamy, Clayey, (note 2:1 Clay) ` L P PS PS U U U U 9) Soil Structure (12-36 in.) S S PS S PS Clayey SoilsPS U U U I) Soil Depth (inches) S S S S rsD PS PS tr U U i) Soil Drainage: Internal S S S S PS PS U U U External S S S S PS PS PS PS U U U U i) Restrictive Horizons Available Space S S. S S PS PS PS PS U U U U 1) Other (Specify) S S S S PS PS PS PS J U U U 1) Site Classification �f n zJ—f U—UNSUITABLE Recommendations/Comments: S—SUITABLE PS—Provisionally Suitable Described by Title - C3 Date�U4� SITE DIAGRAM DCHD (6-82) � ti 1� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department ' Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL, NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit F 2. Address _._ . 13uOnes4 Phone 3. Property Owner if Clifferent than Above Address 4. Permit To: a) Install Alter Repair - b) Privy Conventional __.!:�Other Type—_ Ground Absorplion �s c) Sub-Division��� Sec. Lot No. 5. System used to serve what type facility: House,_ Mobile H�rne_E3usai+s.5 _ Industry-.- Other --- b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms__ Bath Rooms_. 2- Den w/Closet_ _ b) If Business, Industry or Other, State: Number of persons seried �.. What type business, etc. _ _ ---- Estimate amount'of waste daily (24 hours)-- 7. ours)___ 7. Number and type of water -using fixtures: commo7es _ urinals—_ garbage .disposal lavatory showers'Washing machine�� dishwasher 1 _ sinks ' 8. a) Type water supply: Public_ �� Private---- Community b) Has the water supply system been approved? Yes_ -_-"No__ 9. a) Property Dimensions_X — Q-_-- --- b) Land area designated to building sit:.�_6 c2s2------ c) Sewage. Disposal Contractor__. --- 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? .What type? This is to cortify that the. information is correct to the best of my. knowledge. Date Owner Signature OWNER IS SOLELY RESPON131BLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing ections to p y: DAVIE COUNTY HEALTH DEPART:IENT SITE EVALUATION CONSENT FORM INSTRUCTIONS/PREREQUISTES 1. Complete the form below and return it to the Davie Co. Health Department. 2. Along with the form, remit the amount due as shown on enclosed statement. 3. Carefully follow the procedures as outlined in the enclosed "Information Bulletin". 4. Notify Health Department upon completion of item number 3. NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIA11 WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO THE(DAVIE COLTUTY HEALTH DEPARTMENT,P.O. BOX 57) (NOCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM LOCATION OF PROPERTY: �Jle� DATE RECEIVED (office use only) yes nom (1.) I am the owner of the above described property. yes no (2.) I am not the owner of the above described property, however, I certify that I have consent from ,owner to I owner's name obtain a site evaluation by the health Department for the purpose of determining the suitability for a ground absorption sewage disposal system. yes no (3.) I hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures necessary to determine its suitability for a ground absorption sewage disposal system. DATE �— SIG�ATURE (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: V er Only wner's designated representative 0 Anyone requesting results n Only those listed below DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) 53 w n , 5-'v ONE NUMBER ADDRESS 144 Cr4SQ- SUBDIVISION NAME L n!)Oli,41 LOT # DIRECTIONS TO SITE C '1"O C�QnIATZe� , LOC -7- ��C,4Avh to l cr`-o l Q Ona A,�A. ,—LLA, DATE SYSTEM INSTALLED I'7�3 ' NAME SYSTEM INSTALLED UNDER A? TYPE FACILITY AN Ml' , NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY 1w SPECIFY PROBLEM OCCURRING :�O4 6O S%eC:AQ JC> DATE REQUESTED 'T/ ��9 INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 i� APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT ' Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville,- N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Req u d B r /NJ 2. Address 3. Property Owner if Differe t than Above Address Home Phone— Business Phone 4. Permit To: a) Install Iter Repair b) Privy Conventional�Other Type Gr7,��l d Absorption c) Sub -Division ( Sec.Z Lot No% 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people ,>C 6. a) If house or mobile home, stpt��©home and number of rooms. House Dimensions—!) -4Z Bed Rooms Bath Rooms :I-- Den w/Closet 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 ,)— lavatory I.— urinals garbage disposal showers 7!:� washing machine dishwasher /Private_ inks / 8. a) Type water supply: Public s� Copimunity b) Has the water supply system been approved? Yes Y No 9. a) Property Dimensions / ©co x lS'� b) Land area designated to building sAe - c) Sewage Disposal Contractor ��—• —�� 10. Do you anticipate any additions or expansions What type? the facility this sewage system is intended to serve? This is to certify that the information is corre o e bes knowledge. DateOwner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE ITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: AdvpAl DCHD (6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 ! Mocksville, N.C. 27028 SOIL/SITE EVALUATION j Name— Date Address Lot Size FAr.TOPA ARFA 1 ARFA 9 AREA 3 ARFA d IE 1) Topography/ Landscape Position S P S PS S PS ��----00pp U U �) Soil Texture (12-36 in.) Sandy,S Loamy, Clayey, (note 2:1 Clay) FP .,_ PS U PS U S PS U 3) Soil Structure (12-36 in.) Clayey Soils (:tP S PS S PS U U U U g Soil Depth (inches)(t; S PS S PS U U U U i) Soil Drainage: Internal d5) S/� S PS S PS U U U U External &)—.---- S S __ US US i) Restrictive Horizons Available Space S S PS S PS U U 1) Other (Specify) S PS U S PS U S PS U" S PS U 1) Site Classification U—UNSUITABLE Recommendations/Comments: S—SUITABLE CPS—Provisionally Suitable Described by / _ Title SITE DIAGRAM DCHD (6.82) Date Z�W_ DAVIE COUNTY HEALTH DEPARTMENT (� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION * NO E: Issued in Compliance with G.S. of ENorth Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name r%r f �r� j �' f� �'' Dates, ,'. Location Subdivision Name Lot No. Lot Size House Mobile Home. No. Bedrooms t No. Baths — r No. in Family _ Garbage Disposal YES ❑ NO Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES ni NO -❑ Type Water Supply _-- or Block No. _ Business Speculation Specifications for,,System: *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 Diagram: System Installed by,. - A/ J Certificate of Completion 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. 'i 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 Diagram: System Installed by,. - A/ J Certificate of Completion 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.