155 Alamosa Drive Lot 13DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
*iWTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIIATION 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. !�f/
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME AS PROPERTY ADDRESS DATE
LOCATION 2&-zlZ � r/-/ �[/C' Opt/ /i° Y V �9�nC"dY /.7 jv,,;eL, adt/
v
SUBDIVISION NAME ,�,/'/�n/�'�i /�� I/ LOT NXERSEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE - Q, # BEDROOMS # BATHS -�2 # OCCUPANTS GARBAGE DISPOSAL: Yes(j�
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE. !Mlltd TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) D NEW SITE G/REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE J�?A GAL. PUMP TANK
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
GAL. TRENCH WIDTH �G ,' ROCK DEPTH _a2L" LINEAR FT. /S D
***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.
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:80-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY
AUTHORIZATION NO. 3 OPERATION PERMIT BY DATE 11 /
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF B.S. CHAPTER 130A, SECTION .1988 "SEWAGE TREATMENT AND DISPOSAL. SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FRICTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
vK". S 3 -�r'�i �Y}� �z,rvlS ;+.:ii rS 1..4Y. /'i .;i♦ ..-:.J"sil..�"!-w 'ri r.k.^'va :r .:t -i.'+. ., :-.ea .-- tri v', i -.. ,.
�.�
-, Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
}
P.O. Box 665
Mocksville, N.C. 27028. ,
.. AUTHORIZATION FOR WASTENATER SYSTEM CONSTRUCTION
J
(Issued .incoipliance with Article 11 of
G.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.***
AUTHORIZATION NUMBER
WE - DATE N2,
.
NAME ON IMPROVEMENT PERMIT. (If different than above)
nn
4,41 y'4:
SITE LOCATION
' t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P @ (� Wjj
LEDavie County Health Department '" a v
Environmental Health Section
P. O. Box 665 Ap}�
Mocksville, NC 27028
1. Application/Permit Requested By `��'! �- ,,�1 !
Mailing Address r l') /oS%`nC // Home Phone
L. dAJ Pt--- A-1 Business Phone
2. Name on Permit if Different than Above
3. Application for: O General Evaluation Septic Tank Installation Permit
No. of Showers Water Usage Figures
7. Type of water supply: Q-lTu-blic ❑ Private ❑ Community
8, Property Dimensions /•S 0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? ❑ Yes Er 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:
R14"'ro-f
� JOA(- -D a- a
This is to certify that the information provided is correct to t b t of my
incurred from this application.
DATE
ndarstand I am responsible for all charges
SIGNATURE
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form hLM be completed by the owner or a person authorized by the owner:
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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1ro3)
4. System to Serve: ❑ House p'Mobile Home
❑ of Public Assembly
C3 Business C3 Industry C3 Other
LP�lace
J3L6l-nk ownD aLo��=F
5. If house, mobile home: Subdivision .�- A Q��i /V -r)
31B-❑
Section/&M S Lot # 1313-
0Basement/Plumbing
No, of People
❑ Basement/No Plumbing
No. of Bedrooms 3
2 --Washing Machine
No. of Bathrooms
2"61shwasher
Dwelling Dimensions �y X G�
❑ Garbage Disposal
6. If business, Industry, place of public assembly, other: Specify type
No, of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: Q-lTu-blic ❑ Private ❑ Community
8, Property Dimensions /•S 0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? ❑ Yes Er 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:
R14"'ro-f
� JOA(- -D a- a
This is to certify that the information provided is correct to t b t of my
incurred from this application.
DATE
ndarstand I am responsible for all charges
SIGNATURE
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form hLM be completed by the owner or a person authorized by the owner:
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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1ro3)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/ Landscape Position
9)
S
S
S
S
PS
PS
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
(11
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
P
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S.
S
S
PS
PS
PS
U
U
U
{) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE' S—SUITABLE �PS—Provisionally Suitable _�
Recommendations/Comments: a
Described by Title Dates
SITE DIAGRAM
N,6111o"
DCHD (6-82)
MEW
/17r