156 Alamosa Drive Lot 24t Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
} P.O. Box 665
Mocksville, N.C. 27028
{ AUTMDRIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance 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.***
AIMRIZATION M JMBER
NAGE A—o _ L N •� DATE 10 -� �5� No U E 05
MANE ON IMPROVEMENT/PERMIT (If different than above) / 1
SITE LOCATIONCil/d CI //.4 �/ 1/ ""/i�/�105/`I �/ �C� 7ili A-0 f
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
a
IMPROVEMENT PERMIT
f*WTEmf 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 PROPERTY ADDRESS AlArnos-19 /,Jle DATE
LOCATION ,lT�i%l70 w jeor-
SUBDIVISION NAME (�/JDlJ'(iA�� I/ LOT NUMBER SEC. /BLOCK NUMBER :Z—,A7
RESIDENTAL SPECIFICATION: BUILDING TYPE ,e" a # BEDROOMS yJ # BATHS # OCCUPANTS GARBS DISPOSAL: Yes/0
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE P TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) c I ""FEW SITE _Z REPAIR SITE
'SYSTEM SPECIFICATIONS: TANS( SIZE 2&2 GAL. PUMP TANK GAL. TRENCH WIDTH , ROCK DEPTH LINEAR FT. Zo
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 Al
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FILL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:WI :30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
AUTHORIZATION NO. OPERATION PERMIT BY 4—m=ez - 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 10/95
i - DAVIE COUNTY HEALTH DEPARTMENT
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 .1980 Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS r% OS fp�' DATE / •�Sy
LOCATION ,A�I�7 15.S -A) +t0r-
SUBDIVISION NAME LOT NUMBER` SEC. /BLOCK NUMBER
RESIOEN?AL SPECIFICATION: BUILDING TYPE # BEDROOMS #BATHS_ # OCCUPANTS GARBAGE DISPOSAL: Yes/0
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPq-E/SHIFT # SEATS ,INDUSTRIAL WASTE: Yes/No
LOT SIZE OW TYPE WATER SUPPLY ' DESIGN WASTEWATER FLOW IGPD) CcwjJ NEW✓SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE Il ? GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ,:P,f•• LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
*HTHIS 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.
I
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
3`!
AUTHORIZATION NO. OPERATION PERMIT BY 4G 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 FRICTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
ry
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksvilie, NC 27.028
1. Application/Permit R quested By ` ` `-4 Z,
Mailing Address l c ,, // Home Phone
lg J Li drt/ fig, Al, e , Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluatlon Septic Tank Installation Permit
4. System to Serve: ❑ House rd'Mobile Home O LP'lace of Public Assembly
O Business ❑ Industry O Other ,3 L6 UnknownD -'� aLoG4 F
5. If house, mobile home: Subdivision I R �G AV -r E) Section/ MOSALot # a�' 8-F
O Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 0-Wi ashing Machine
No. of Bathrooms 215ishwasher
Dwelling Dimensions 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 Showers
No. of Water Coolers
Water Usage Figures
7. Type of water supply: p�'ublic ❑ Private O 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 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 i, 1989.
Directions to Property:
Alamo
D
This is to certify that the information provided is correct7tb t of my
incurred from this application.
2— Q
DATE
J
SIGNATURE
I am responsible for all charges
MUST CHECK ONE: O 1. 1 OWN the property. O 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
DCHD (1193)
SIGNATURE
W,
Name—
Address
MAYO
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FAr.T0RC ARFA 1 APPA 9 AREA .q APPA A
1) Topography/ Landscape Position
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
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
pS
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS3
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE / PS—Provisionally Suitable
Recommendations/ Comments: o ,
Described by Title ��� Date
SITE DIAGRAM
DCHD (6.82)