P0088 Alamosa Drive Lot 21 F. it-:: r -P ° 7i• a h .is'^i �.. _ �.,, ,..�'-va_ S wtz�'.Y L, -::.✓ -� , . �, f: •. , . � � _ _ _, ,.. _ ;
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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 � ijIOSLL �r. DATE
LOCATION
SUBDIVISION NAME/DL' Lf' ��V� LOT NUMBER SEC./BLOCK NUMBER _
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL.: Ye so
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIA. WASTE: Yes/No
•.,LOT SIZE Idey/SD TYPE WATER SUPPLY A_ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TAM{ SIIE � GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH :2.2f LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
WTHIS 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!
**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
�F
AUTHORIZATION N0. tj 69'7' OPERATION PERMIT BY `! DATE V'11pi*6
**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 INA, 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
,n•3 N;;\. thq-.+<1 fy t. i. ,ay.l r-. ... ,.. .G �q..✓.s t... ;i ��.t r y .:< V � ..y +2,Fi .sr4 ri''">t t t! V'x t .. .. , .. ,.
Davie County Health Department
Jr _t ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
r Mocksville, N.C. 270228
AUTHORIZATION FOR WASTEWATER SYSTEMCONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 13OA, Wastewater Systems)
***This Authorization For Wastewater System Construction oust 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 Peioits.+**
AUTHORIZATION MJ MBER
NAME DATE �i — �/ 9 N2 0-0 98
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION d i// e-ry
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NSTICE*H THIS AUTHORIZATION F R WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMMEMTAL TH SPECIALIST ` DATE
DCHD 10/95. ":
r. APPLICATION FOR SITE EV TS P 1 a �f
Davie County Health Department j
Environmental Health Section
P. O. Box 665 APR
Mocksville, NC 27028
i
1. Application/Permit R quested By
Mailing Address �� �� _ Home Phone
A J Al, L' , 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 -1Mobile Home CC
t� O Place of Public Assembly
O Business ❑ Industry 00 1 ther BL6g Anownb
11r B�
5. if house, mobile home: Subdivision 1- A Q�li N SectionA M S Lot # a F
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
7. Type of water supply: 2-1:rublic
8. Property Dimensions S 0 Sewage Disposal Contractor
No. of Water Cc olers
Water Usage Figures _
❑ Private
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes
❑ Community
*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:
Ala,
6 t44 -D a- 6 tax
This is to certify that the information provided is correct tot bt of my
Incurred from this application.
DATE
SIGNATURE
I am responsible for all charges
CONSENT EM �M EVALUATION IQ 59 DONE QN ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: O 1. 1 OWN the property. ❑ 2. 1 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.
DATE S.GNATURE
DOHD (ip3)
❑ Basement/Plumbing
No. of People
❑ Basement/No Plumbing
No. of Bedrooms
3
2 - -Washing Machine
No. of Bathrooms
215shwasher
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 Showers
7. Type of water supply: 2-1:rublic
8. Property Dimensions S 0 Sewage Disposal Contractor
No. of Water Cc olers
Water Usage Figures _
❑ Private
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes
❑ Community
*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:
Ala,
6 t44 -D a- 6 tax
This is to certify that the information provided is correct tot bt of my
Incurred from this application.
DATE
SIGNATURE
I am responsible for all charges
CONSENT EM �M EVALUATION IQ 59 DONE QN ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: O 1. 1 OWN the property. ❑ 2. 1 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.
DATE S.GNATURE
DOHD (ip3)
Name `
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date��
Lot Size
FAr:TOPR ARFA i ARFA 9 AREA R APPA A
1) Topography/ Landscape Position
S
S
S
,�5�
(iPS%
PS
PS
PS
U
U
U
Z) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
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
dD
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
SS
S
S
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
11111629,
U—UNSUITABLE S—SUITABLE /PS—Provisionaliv Suitable
Recommendations/Comments: L
Described by _
SITE DIAGRAM
DCHD (6-82)
Title ,::� Date