162 Alamosa Drive Lot 23i rti;e,t t.+. v�',f'..fr; Yf .,fy .. Y,t =PJ' s V:..i.j a .. •t {, ,. tit. . . , is r'it `rl.rt._r '-f . - . .
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
_.. (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.***
®,, AUTHORIZATION NUMBER
NAME'` �Zt &C DATE i'9 —Q—Q F G f
NAME ON IMPROVBW PERMIT (If diff rent than above)
,n �
SITE LOCATION
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMIENT 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 to P �� PROPERTY ADDRESS - 141A A ?n OSS r" DATE
LOCATION . Jr -
SUBDIVISION NAME e- LOT NUMBER .I--? SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE I/ i L # BEDROOMS # BATHS ` t OCCUPANTS _.:�/ GARBAGE DISPOSAL: Yes
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE ,1 PEDF�IE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE AD /s'0 TYPE WATER SUPPLY e4e, DESIGN WASTEWATER FLOW (GPD) NEW SITE bl REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZER P GAL. PUIMP TANK GAL. TRENCH WIDTH j ' ROCK DEPTH ' � LINEAR FT. � t
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 /4y / /
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:08-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8768.
OPERATION PERMIT
SYSTEM INSTALLED BY .Z,
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 .1908 "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
.. ~ y _/' .fps - 1 �..� .�^�. •—.�� J ..
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
r IMPROVEMENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
systema 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 R.0 f%S PROPERTY ADDRESS _ 141,4 Tn o.Yg DATE
LOCATION Al—
SUBDIVISION NAME i LOT NUMBER -.S SEC./BLOCK NUMBER'
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS '� # BATHS ,.V # OCCUPANTS _:!�z GARBAGE DISPOSAL: Yeso
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE, �ti PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIIE r"< -T) TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE V REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIL;/bf1P GAL. PUMP TANK GAL. TRENCH WIDTH _,' r ROCK DEPTH 'i '' LINEAR FT. S-0 �
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 A
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FILL 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 BYDATE S
**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 SATISFACTOPILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
i
i
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS P
Davie County Health Department a v
Environmental Health Section D
P. O. Box 665^ APR 0 ;
Mocksville, NC 27028 I
1. Application/Permit R uested By a't'e L ¢'-/ !1 t
Mailing Address /9 �� ,� Home Phone
�i i ' ►. � P /y, Business Phone
2. Name on Permit if Different than Above
3. Application for: O General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House O'Mobile Home ❑ CCP��lace of Public Assembly
El Business ❑ Industry [--1OtherBL6 ZJnknown•D
'r
5. If house, mobile home: Subdivision A �� N � 9 Section/9LbMvSA Lot # 2 3' jS'F
No. of People `7"
No. of Bedrooms J
No. of Bathrooms
Dwelling Dimensions
A/9 .76)
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures _
❑ Basement/Plumbing
❑ Basement/No Plumbing
C' Washing Machine
215shwasher
❑ Garbage Disposal
7. Type of water supply: P-96'blic ❑ Private ❑ Community
11)8. Property Dimensions /Pel X /-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 1, 1989.
Directions to Property:
Rla * Z)
B10,1114- D *.6��
This is to certify that the information provided is correct to th�b t of my
Incurred from this application.
.Z- Q
DATE
nderstand I am responsible for all charges
SiG NATURE
•► ► •: •� • �•�_ • •:• � - -:•- . til
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. i 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:
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.
DCHD (1193)
DATE SIGNATURE
4
r
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS ARFA 1 ARFA 9 ARFA 3 ARFA d
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
S
Clayey Soils
�
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
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
') Available Space
S
S
S
pS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification)67
1
U—UNSUITABLE S—SUITABLE /,`P -$—Provisionally Suitable
Recommendations/ Comments: I&
Described by� Title's Date
SITE DIAGRAM
0
DCHD (6-82)