P0089 Alamosa Drive Lot 9DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** This improyement 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 j% S PROPERTY ADDRESS 1`► �(�iY1(LC� �1(�• DATE
LOCATION ly<A '00C
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER _ _ A
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: YesO
COMMERCIAL SPECIFICATION: FACILITY TYPE ,# PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIIE /513 !�(> TYPE WATER SUPPLY F r�, DESIGN WASTEWATER FLOW (GPD) Tld NEW SITE tt''' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIIE 1600 GAL. PUMA TANK` GAL. TRENCH WIDTH 2 ROCK DEPTH LINEAR FT. /J-�4
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
**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
v
AUTHORIZATION NO. L014OPERATION PERMIT BY h1aill 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
t.. v f i" '�.�,t ?•;�♦ fRNi+� . rl'i M>r..�K: �.i: .. rh?'a"U.�' yx p'tJ' •{ry.�r.;r ~a-;-!-lr,� �:i,.x.-4. }i.:��:i '�y:.4..� .._ .- - •... •,.
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
tai—r
Mocksville, N.C. 27028
J 4 ; �-
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance witi 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.+**
NAME �,�, r __DATE /� ` J/'9� pAh�UTHORIZATIONN/h�IB/•E�gR
2 - 0 0 . J
NAME ON IMPROVEMENT PERMIT (If different than above) ,r1
SITE LOCATION �O &-epi' 2&4P 4"A Alf- - � f� G�'va
COMMENTS/CONDITIONS ON AUTHORIZATION TO�CpNSTRUCT WASTEWATER SYSTEM
x:.fm{FOTICE THIS AUTHORIZATION FO TEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
r
ENO
RDKNTAL HEALTH IALIST DATE
DCHD 10/95
s., APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NO 27028
@71 [EodIE
APR Lr'0
1. Application/Permit R quested By ✓ P Z v/�
Mailing Address II� �� �� Home Phone
%} /�t' �. 1�,.1/ f it/ C� , Business Phone_7 �?g a / oo
2. Name on Permit if Different than Above
3. Application for: O General Evaluation Septic Tank Installation Permit
4. System to Serve: O House (r3'Mobile Home f� D LLPlace of Public Assembly
0 Business O Industry O Other Big Ukn nownb ¢ &04-A:.F
' -rte r �
S. If house, mobile home: Subdivision A �� /V 1 r� Section/gl M S lot # q "
No. of People - /-/
No. of Bedrooms J
No. of Bathrooms
Dwelling Dimensions /(7/ x G�
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: 91,-P'ublic
No: of Sinks
No. of Urinals
No. of Water Coolers _
Water Usage Figures
0 Private
8. Property yDimensions /DO X /S D
Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? O Yes
If yes, what type?
O Basement/Plumbing
0 Basement/No Plumbing
p' Washing Machine
0'6shwasher
0 Garbage Disposal
S
p Community
*NOTE: Improvements Permits shall be valid for a period of 5 years from date iasued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
Rla'ear
B 14tAL ID a- a
This is to certify that the information provided is correct to t bedt of my
Incurred from this application.
DATE
SIGNATURE
I am responsible for all charges
CONSENT FOR SITE EVALUATION IQ BE DONE QN ABOVE DESCRIBE;? PROPERTY
Fanddisposal
ECK ONE: O 1. 1 OWN the property. O 2. I DO NOT OWN the property.
ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
system.
DATE SIGNATURE
DCHD (1/93)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS AREA 1 AREA 2 AREA 3 ARFA d
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,S
S
S
Loamy, Clayey, (note 2:1 Clay)
'� PSJ
PS
PS
PS
ALT
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
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
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
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE
onaliy Suitable
Described by _�J��� Title c Date
SITE DIAGRAM
iso
DCHD (8-82)
v
dishwashe m _
S. a) Ty water s ppl�bublic P-ri e' Communit
b). Has the wate uppty' system been ap�roved? Yes L� No N
9. a)_Po arty Dim nsions /00 X / �'d t. ! >� Q 5 W
b) tan area de ignated to buildin�el,
�sige Dispo al d tractor q .F.-/''
10. Do you anticipat any..addttrons o e pansions of the facility this s wage sysem is intended to serve �_
Whab ty e?
c l = '�
9.
his -is certify that the nfo"'ion is cortEci te- he best o knowl de ge. -
O'� ! 1 t11 i�+
D�� - '' 4.� 11 1 I I T) Ow "r S gno-t W
I5
WNER I '.j3OLRY Rff.SPONSIBL FOR on
WI H ALL Sr!�ID LOCAL LAWS
C I All w Sys for pros
erections to operty: --f~ C
..o r� I £ ' rJ o Q d 05
J
A ? m
OL
L Z Z
d a..N ins d �
O �' 1 1 rJ r.T • - `, 1 \ i� L1 `/ t7
Cl C V V
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9
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