P0007 Alamosa Drive Lot 25 B-FDAVIE COUNTY HEALTH DEPARTMENT
-06 IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
/D
114-4-70,
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater '/ / n
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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME
..—
PROPERTY ADDRESSi
DATE /0
LOCATION /%.(r.a_
SUBDIVISION NAME LOT NUMBER S' SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATIOMI: BUILDING TYPE # BEDROOMS , #BATHS #,INTS GARBAGE DISPOSAL: Yes6
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPI-E/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE 1DD.Y/Sly TYPE WATER SILLY e4O DESIGN WASTEWATER FLOW (GPD) �'� D NEW SITE vo REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /1n A GAL. PIVD TANK GAL. TRENCH WIDTH " ROCK DEPTH 9LINEAR FT.. SJ -
OTHER
REOUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM'CONTRi TOR *1ST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
w -
IMPROVEMENT PERMIT BY
YA�I
**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
[::tj
AUTHORIZATION NO. Q�Q �% OPERATION PERMIT BY DATE 16d;
**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
/ '*`^-r '+;:':i ".:��',t -- ...'(irti � :. t `ra rte. L.1 i;: �.., ., j;'. .x,^• .. ...
� M Davie County Health Department A.
ENVIRONMENTAL HEALTH SECTION
P.O.aBox 665
r.
Mocksville N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued incompliance with Article 11 of
6.S. Chapter 130A, Wastewater Systems)
***This Authorizatiot.For Wastewater System Construction must be issued by the Davie CouCty 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
'Aj . Q' 9S � AUTHORIZATION NUMBER
°t:7
NAME ON IMPROVEMENT PERMIT (If different -than above)
SITE LOCATIDhI
LOOMS/CXITIaG ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
**WICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FORA PERIOD OF -FIVE (5) YEARS.
ENVI AL Ie IALIST DATE
'DCHD 10/95 -
.. ,�.._'.t �s �, '-- _ rum-__�.1_ .�._ __.., �. -- �_�_-r. �.. s.--• --- ,._-m ---' -- ----- ti- -'- - - � - -
' APPLICATION FOR SITE EVALUATIONIIMPROVEi111ENTS P MI
Davie County Health Department Ll 1J
Environmental Health Section
P. O. Box 665; APR
Mocksville, NC 27028 1 h
1, Application/Permit R uested By �b Z% �K �/ j L
Mailing Address (.) ,%� Home Phone
A J. F_4 Al, C' , Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tani, Installation Permit
4. System to Serve: ❑ House 0 -Mobile Home f� ❑ LPlace of Public Assembly
❑ Business ❑ Industry✓ ❑ Other B�� UnknownD
5. If house, mobile home: Subdivision AyA Section/91�MvsA ALot #F
6. If business, industry, place of public assembly, other: Specity'type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
❑ Basement/Plumbing
❑ Basement/No Plumbing
2' Washing Machine
215shwasher
❑ Garbage Disposal
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: 0Y1:ru-blic ❑ Private ❑ Community
8. Property Dimensions Z0&2 x /S 0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑Yes ET 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: �atm- F
This is to certify that the Information provided is correct to
incurred from this application.
-2-o
DATE
of my kq6wledgg, and -1 understand I am responsible for all charges
SIGNATURE
MUST CHECK ONE: ❑ 1. 1 OWN the property. L 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MM 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 (1/93)
SIGNATURE
`?'
No. of People
No. of Bedrooms
3
No. of Bathrooms
Dwelling Dimensions
A/x
6. If business, industry, place of public assembly, other: Specity'type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
❑ Basement/Plumbing
❑ Basement/No Plumbing
2' Washing Machine
215shwasher
❑ Garbage Disposal
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: 0Y1:ru-blic ❑ Private ❑ Community
8. Property Dimensions Z0&2 x /S 0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑Yes ET 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: �atm- F
This is to certify that the Information provided is correct to
incurred from this application.
-2-o
DATE
of my kq6wledgg, and -1 understand I am responsible for all charges
SIGNATURE
MUST CHECK ONE: ❑ 1. 1 OWN the property. L 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MM 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 (1/93)
SIGNATURE
4
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
/) SOIL/SITE EVALUATION
Date��
Lot Size
FACTORS APPA i AREA 9 APPA 3 AQGA d
1) Topography/ Landscape Position
S
S
S
cb
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
ij
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
U
U.
U
t) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
OU
PS
PS
PS
U
U
U
i) Restrictive Horizons
') Available Space
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
,,>J
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE /PS—Provisionally Suitable
Described by ��� Title 7cJ Date
SITE DIAGRAM
A^?)
DCHD (6-82)
lavatory showers washing machine
dishwashe iMes r 0 � C
8. a) Type waters pplAublic_ Communit
b) Ha the wate Au�ppsystem been approved? Yes L� No—
q—(V �,
L9. a}.exo erty Dim nsions 4 �d ! __ y r� S C) �'� W
. b) tan area de ignated to ATT ding site
. ge Dispo al 69itractor C' a r A =,-� r,,,
10. Do you nticipat aha or expansions of the facility this s wage sys Fm is intended to serve
- �'i-
WhaU ty e? '
9 his is to certify that the nforMation is correct -to- he best o y n -o -w ge. +
-._-
ii
Da,te �, 1 r " ' I :r' Ow r S gna - 15
I I _ WNER I `DOL LY RESPONSIBL FOR COMPLIANCE WI H ALL S TE AND LOCAL LAWS
c I All w Sys for proc
erections to operty:
p r r pi Q 09
91r1Nino w :[
CO
am
, L
« T b �3S 6t7
,I CO r.. Z ZZ
CO
rD
ri 1� � ,r � • _
» 60 zug
• ' � �� I 1.
L w Nunn
d�
r, v. wnwv
MOCKSVUE. NORTH CAROUNA 27028
(704) 634-8760 }f k
October `9, 1995
Roy Potts
P. 0. Box ' 11
Advance, PSC 27006
4 Permit/ATC#ls 0006 (Lot 24), 0007 (Lot 25), 0008 (Lot 23)
& 0009 (Lot 22) (Woodvalley/Block.B-F) $200.00
Payment Due Upon Receipt of This Bill
-: DETACH AND UAILWITH YOUR CHECK YOUR CANCELLED CHECK IS YOUR RECEIPT.
-------------------------------------------------- — - — — — — — — — —
let -09-95 lPermit/ATC#: 0006 (Lot 24) 1 $ 50.00
---------+------------------------------------------+--------
10-09-95 (Permit/ATC# 0007 (Lot 25) 1 50.02
------ ------------------------------------------------------- ---
10-09-95 Weroit/ATC# 0008 (Lot 23) 1 50.03';
---------+------------------------------------------+-------
10-09-95 (Permit/ATC# 0009 (Lot 28) 1 50.00;
---------+----------- ------------------------------+--------
I Roy Potts/Woodvalley (Block B -F) I
---------+--------------------------------------------------
--------_I---------------------- ------ -------+--------..
A\
a -j.
---------+-----------------------------+-------
� I
---------a-------------------------------------------+-------
I AMMJNT DUE NOW - l $200.-00a
• � F