P0087 Alamosa Drive Lot 20 FDavie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
;t
AUTHORIZATION 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 whe applying for Building Permits.***
AUTHORIZATION NUMBER
NAMErV S DATE i�?�y/9 r/ N� 0,8 7
NAME ON IMPROVEMENT PERMIT (If different than above)
�.L�/VANAM
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
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 .1900 Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS A Q m) S a- & • DATE �—
LOCATION / %� /F un /Q - V ✓ f�'.v ! �/ rA - . h •P �`
SUBDIVISION NAME�f�/�//�,/t�1 / LOT NUMBER SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS, # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye&
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE lJP% %l TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) � NEW SITE G'� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/V,/7a GAL. PUMP TANK GAL. TRENCH WIDTH 3/ ,• ROCK DEPTH % LINEAR FT. /S
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 BYf/
**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 1704) 634-8760.
OPERATION PERMIT
AUTHORIZATION NO.
SYSTEM INSTALLED BY
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 10/95
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMErIT.PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewate
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 it of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME A4914 jells— PROPERTY ADDRESS Ala ))t'l s 6L • DATE jy /I�
LOCATION 1/9/-
G. /�u.� i`� Ja :/X,
SUBDIVISION NAME r�%/Jr��%� ? /.�F�1 f LOT NUMBER r^���i SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE m # BEDROOMS. �_ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye 4
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE fi�' S' _ TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 1 NEW SITE t -"o REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/ GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. /S f
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY+j`
**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 TIDE.
DCHD 101.95 y
APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PE
Davie County Health Department r E @ L52
DUE.
Environmental Health Section
P. 0. sox 665 FPRMocksville, NC 27028 i�:•'r
1. Application/Permit Rested By \ e L iJ J,3n i
Mailing Address qu
J-:� a'< ZZ Home Phone
A Jv X1,1/ Al, Business Phone
2. Name on Permit if Different than Above
3. Application for: 0 General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House "obile Home ❑ (Place of Public Assembly
❑ Business ❑ Industry ❑ Other IIL6 UnknownD
r
5. If house, mobile home: Subdivision A 9�, N 7A Section& M S Lot # .7t) 13 -
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers _
❑ Basement/Plumbing
❑ Basement/No Plumbing
D' Washing Machine
2"Cishwasher
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: 915'ublic ❑ Private ❑ Community
8. Property Dimensions 10O X IS -0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EY 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, 198zS.
Directions to Property:
Rla�
This is to certify that the information provided is correct to t 'bt of my
Incurred from this application.
.z 0
DATE
and'i\understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION IQ 09 DONE QN ABOVE
MUST CHECK ONE: ❑ 1. 1 QM the property. ❑ 2. 1 QO 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.
DATE SIGNATURE
DCHD (1193)
4
No. of People
No. of Bedrooms
3
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers _
❑ Basement/Plumbing
❑ Basement/No Plumbing
D' Washing Machine
2"Cishwasher
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: 915'ublic ❑ Private ❑ Community
8. Property Dimensions 10O X IS -0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EY 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, 198zS.
Directions to Property:
Rla�
This is to certify that the information provided is correct to t 'bt of my
Incurred from this application.
.z 0
DATE
and'i\understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION IQ 09 DONE QN ABOVE
MUST CHECK ONE: ❑ 1. 1 QM the property. ❑ 2. 1 QO 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.
DATE SIGNATURE
DCHD (1193)
Address
W"n
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size osaaff
FACTORS AREA 1 AREA 2 AREA 3 AREA d
i) Topography/ Landscape Position
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
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
<�55
PS
PS
PS
U
U
U
U
I) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal�,
S
S
S
4!b
PS
PS
PS
U
U
U
U
External
S
S
S
S
Ke: -'PZ
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S-
PS
S
PS
S
PS
U
U
U
I) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionali Sui
Recommendations/Comments: e '5f
Described byTitle Date
SITE DIAGRAM
DCHD (5-82)