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1835 Farmington Rd (2)DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Q Mocksville, NC 27028 (336)751-8760 J IMPROVEMENT/OPERATION PERMIT Account #: 990003901 Billed To: Farmington Baptist Church Reference Name: Rev. Scott Lyerly Proposed Facility: Church Tax PIN/EH #: 5842-67-6035 Subdivision Info: Location/Address: 1835 Farmington Rd -27028 Property Size: 3.1 acres **NO TE* This Improvement/Operation Permit DOES NOT authorize the construction 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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ ti Commercial Specification: Facility Type �/S it/�h #People s'D6 #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: News" Repair ❑ System Specifications: Tank Size%_ GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Wiiidth � Rock Depth /1�' Linear F accepted Sygtems may also be IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** S-A t9 r Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003901 Billed To: Farmington Baptist Church Reference Name: Rev. Scott Lyerly ATC Number: 4356 Tax PIN/EH #: 5842-67-6035 Subdivision Info: Location/Address: 1835 Farmington Rd -27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUqtION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 2Date: 5; %6- c CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Se4j'g-,Tje4&eyA and given period of time. Yom' 2Io' 14 ►F�,Iia r 30 Qjj l v. Fr ' 1Septic System Installed By: Environmental ealth Specialist's Signature: Date: L DCHD 05/99 (Revised) PlgNsr, seg A4 -{ached k-FFe� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section DP.O. Box 848/210 Hospital Street IIJJ Mocksville, NC 27028 MAR 8 2000 (336)751-8760/ Fax (336)751=8786 A plication For- luati Improvement Permit Authorization To Construct(ATC) ❑ Both FNMNIAL HFAUH ***I ICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed F I Contact Person Billing Address Home Phone _ City/State/ZIP Business Phone Name on Permit/ATC if Different than Above. Mailing Address PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat. Street Address /93E r rm n M, City—MOP BVile—Tax PIN# Subdivision Name Sec ton/Lot# Lot Size Directions To Site: 1)Fi�s nrm,n n p . Fi•1� Turn lP-I.� Date House/Facility Corners Flagged M4 re h to, 0 0010 If the answer to any of the following questions is "yes", supporting documentatio must be attached. Are there any existing wastewater systems on the site? Dyes o Does the site contain jurisdictional wetlands? Dyes Are there any easements or right-of-ways on the site? Dyes Is the site subject to approval by another public agency? Dyes Will wastewater other than domestic sewage be generated? Dye'so IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: Dyes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building H# People 950 # Sinks # Commodes 7 Showers # Urinals Estimated Water Usage (gallons per day) �i�• (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats , Type system requested: Conventional ❑Accepted ❑ Innovative ❑ Alternative ❑ Other Water Supply Type: VCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? Cil' Yes ❑ No If yes, what type? POss ' io_ ohq� e IT 11'1 !i l� . �,SQ-t�QX'� This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. 1 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compl' nce with applicable laws and rules on the above described property located in Davie County and owned by Property owner s or owner's legal repre ntativ signature 3 q _O�1 _ Date Sign given ❑Yes ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # p P00a dg o� h p�s bee n ry) ouQdl PHASE owl - - - ---- �`a FEASIBILITY STUDY FARMINGTON BAPTIST CTJ'IJRCI-i FARMINGTON. INC PARSONAGE Suet NO. OG SEPTE-VUR 21, 2004 NW jYY O NV Spatial Data £� Wirer *NorthTarolina�� Click on the Map to: r Zoomin r Zoomout (: Recenter map r Identify: ITown Zoning Radius Search (feet) rO Zoom Factor. 2X Al (16.8m 7590 pkl c -519 i 79 TTM _t (L06AJ � 9669 j . as (sz4% (L4a31..t....,...... bU3�Ma,xet,.., 7824 6663 SCALE 1: 4131 W4,E Zoom in Zoom Out Full Extent Reset'Map Reference Map Click on map to Zoom to the location. NE 51 SE — --o— — -- — Map L Draw l Draw selec Boundary j- Census Tre City Bound jr County Zor MUIti S, r E911 Fire D jr Flood Pane r Flood Zone F Parcels (— School Dis, Multi % r Soils F Town Zonit (— Townships MUlti S) r Voting Pre( r` Driveways j— Rail Lines P- Street Cent r US/NC Higi Multi S� jr Aerial Phot Physical j� Creeks and (r E911 Addre r Fire Depart j" Schools Qraw. `I MAP C rms map is prep; 0280 inventory of real i this jurisdi( 9W com1=from rei piatsp�aend other F [3 (U m and data. 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Users; hereby notified th aforementioned F Parcel Query information sours consulted for ved information conta http://66.208.132.254/servletlcom.esri.esrimap.Esrimap'.Name=Davie&Cmd=Clk&Left=154... 9/24/04 fT O� 4' Spatia! Data [�p1C�r&r qp.0 �W NoRarolRna� Click on the Map to: f Zoomin r Zoomout r RecenterMap r Identify: County Zoning Zoom Factor. ZX i Radius Seam (feet) I" r NW SW sma I NE- SCALE 1: 4131 fl QV Zoom In Zoom Out Full Extent Reset,Map. Zoom To Scale . j ;Find An Address. Parcel Quo Reference Map Click on map to Zoom to the location. . —a,- a — — I Map L Draw Draw selec Boundary j- Census Tra City Bound I✓ County Zor r E911 Fire 0 r Flood Pane r Flood Zone F Parcels r School Dial Multi S) r Soils F Town Zonit r Townships Multi S� r Voting Prot Infrastructu (— Driveways j- Rail Lines F Street Cent http://66.208.132.254/servlet/com.esri.esrimap.Esrimap?Name=Davie&Cmd=Redraw&Left=... 9/24/04 €fir 6.11 SJR 7590 ��gVYi a( ► n t 211A fa t R1 A .aa SW sma I NE- SCALE 1: 4131 fl QV Zoom In Zoom Out Full Extent Reset,Map. Zoom To Scale . j ;Find An Address. Parcel Quo Reference Map Click on map to Zoom to the location. . —a,- a — — I Map L Draw Draw selec Boundary j- Census Tra City Bound I✓ County Zor r E911 Fire 0 r Flood Pane r Flood Zone F Parcels r School Dial Multi S) r Soils F Town Zonit r Townships Multi S� r Voting Prot Infrastructu (— Driveways j- Rail Lines F Street Cent http://66.208.132.254/servlet/com.esri.esrimap.Esrimap?Name=Davie&Cmd=Redraw&Left=... 9/24/04 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990003901 Billed To: Farmington Baptist Church Reference Name: Rev. Scott Lyerly Proposed Facility: Church Property Size Water Supply: Evaluation By: On -Site Well Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5842-67-6035 Subdivision Info: Location/Address: 1835 Farmington Rd -27028 3.1 acres Date Evaluated: .� Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L. Sloe % rs HORIZON I DEPTH IVIII i Texture group (" Consistence Structure Mineralogy '/ HORIZON II DEPTH v Texture group /7- Consistence , Structure /1 Mineralogy.. HORIZON III DEPTH 67 Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ' SITE CLASSIFICATION: / LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: OTHER(S) PRESENT: Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S -Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay u. VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 33'_ct NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed IYflt�T Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■[�Y�!■■■■■■■■■■■�:■fi■�■■�■�■■■illy■■■■■■■■�■■■1�■'1■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■!■■■■■ ■■■■■ice■■■■■■■■■■■II�IJ■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■!�■■■■■■■■■■■■110,■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Ili■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENNENiiiiiii=MENNEN' iiiiiiiiiiiiiiiiiiiMEMNONl�i ■■■■■■■■■■■■■■■■■■■■■■■■■■■7�1�:?O'f1►X11■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■rill■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ IV C -TSL II -Y-0 6 / / o N 0 41�� h P,2t-,\V kl) Permittee's_ -- - Na�ine: Directions to property: s DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848 PROPERTY INFORMATION Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Secti AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION 1 Lot: AUTHORIZATION NO: 002695 A Road Name: Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Fornn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS�� # BATHS Xl, — # OCCUPANTS —? — GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE 44214EOPLE # PEOPLE/SHIFT _ # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) ir:2 L NEW SITE_ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK /400 GAL. TRENCH WIDTH s.rj/4 " ROCK DEPTH �/ LINEAR FTAgan OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ,, P AMP A, ear FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. I OPERATION PERMIT AUTHORIZATION NO. OPERATION PERMIT BY: SYSTEM INSTALLED 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 02102 (Revised) Permittee's -� Name: ' Directions to pro perry: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848 Mocksville, NC 27028 Phone #: 336-751-8760 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION PROPERTY INFORMATION Subdivision Name: Section: Lot: Tax Office PIN:# - AUTHORIZATION NO: 092695 A Road Name: Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Fonrl/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pen -nits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # /BEDROOMS—,_ # BATHS , . # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE �n'�•' /PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No a LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE !% GAL. PUMP TANKA)6 GAL. TRENCH WIDTH T(., 'ROCK DEPTH LINEAR FT/,L� OTHER FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 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 1 I 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 02/02 (Revised) Pe�rmlttee's_ NamE: ` Directions to +erty: AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION P.O. Box 848 00265115 A Road Name: Lot: Zip:_ **NOTE** 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. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEllROOMS _�'— #BATHS ; � # OCCUPANTS � GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE / .b'•{ •• Of PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE_ REPAIR SITE SYSTEM SPECIFI�NS:,TANK SIZE �' I !GAL. PUMP TANK <', ' l GAL. TRENCH WIDTH ROCK DEPTH -1 LINEAR FT�/1rflS REQUIRED SITE MODIFICA IMPROVEMENT PERMIT tAY OU�F,`>>`�' c•, IONS: r'. fit, FOR NAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION AUTHORIZATION NO. OPERATION PERMIT BY: SYSTEM INSTALLED BY: �i _DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN CbMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BETAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02 /02 (Revised) Permitte ' VIE COUNTY HEALTH DEPARTMENT Name: `n w A ( l' environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: _ltt S it�C'/•271 J'TO—"'Mocksville, NC 27028 Subdivision Name: , / Phone #: 336-751-8760 �'/� Section: AUTHORIZATION NO: 002694 A AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION Lot: Road Name: Zip: **NOTE** 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. (In coTpliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) , / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 1�_ IS VALID FOR A PERIOD OF FIVE YEARS. AL HEALTH S CIALIST DATE ISSUED P"ttee's'" � J DV E COUNTY HEALTH DEPARTMENT Natrir: ' 1lI '1 (�/jr fG�f environmental Health Section PROPERTY INFORMATION P.O. Box 848 _ Directions to property: �r�%�� a y �Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 f Section: Lot: AUTHORIZATION NO: 002694 A AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - SYSTEM CONSTRUCTION Road Name: Zip: **NOTE** 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. (In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) //—/OZ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _/` # BEDROOMS # BATHS _ # OCCUPANTS _ L/ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS ] INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ` NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OT41AR J;V,�,J 11'd e 10 ( _/ +ter" REQUIRED SITE MODIFICATIONS/CONDITIONS: A/\ - IMPROVEMENT PERMIT LAYOUT J&/ 4 4-0bli I e", � r l xi k/ 1 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT AUTHORIZATION NO. SYSTEM INSTALLED BY: J 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 02/02 (Revised) A Parmitee's' DAVIE COUNTY HEALTH DEPARTMENT Nang:'' �'' ` '` =�� f ` ` �' '''..gip Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: hlocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 r ' Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - - AUTHORIZATION NO: V V e- V _:s ¢; t", Road Name: Zip: **NOTE** 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. (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION " f'• A �` `�` ' f� J G[� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE L`'r� # BEDROOMS�1 # BATHS .? # OCCUPANTS __�L_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT - # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY i0 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. nTUFrz �/�.r !f f` /'`�a rr' � 0 ��I �<7 �.� �(f r� � �"/ �� f �.•� /'� �rfi�..S-... . REQUIRED SITE MODIFICATIONS/CONDITIONS 1 s IMPROVEMENT PERMIT LAYOUT sjr 6 �a a_ 1-7 r 111 � I �SC'l'� �' •1``7 i FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 6 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 TIME. DCHD 02102 (Revised) .. Pcnniuee!s^ DAVIE COUNTY HEALTH DEPARTMENT , Environmental Health Section t , P.O. Box 848 PROPERTY INFORMATION Directions to property: �`' Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION — Lot: t'; AUTHORIZATION NO: (;. ;. 4 A Road Name: Zip: **NOTE** 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. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) r ***NO MI L*** I HIS AU I'HOKIZA'FION FOR WASTEWATER CONSTRUCTION OSI`✓ r IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE - t� # BEllROOMS #BATHS —,,,/ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �. /U NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER �` if T f .� �`'% �' `� (� J•) i'7! !" f /�% r" /' E : f REQUIRED SITE MODIFICATIONS/CONDITIONS: rr r �� rif' IMPROVEMENT PERMIT LAYOUT u J Cl /V ;1 ii ,r FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: �16 1 1 AUTHORIZATION NO. OPERATION PERMIT BY: DATES A "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 02/02 (Revised) �I� 010AAA Perrmitte �- % DAVIE,CO TY HEA TH DEPARTMENT Name: f =`� f �°'�' (� s'`'r 'i� ? f Environmental Health Section PROPERTY INFORMATIO �t, 46 ��. P.O. Box 848 Directions to property:_`"' \ Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION /� 3"r For'h3�15 6� ` AUTHORIZATION NO: MGM, A Road Name: � Zi **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPEdALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS- # BATHS —57 # OCCUPANTS � GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ,,�� rte; LOT SIZE TYPE WATER SUPPLY ' DESIGN WASTEWATER FLOW (GPD)\Y ',' NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT GAL. TRENCH WIDTH ' ROCK DEPTH LINEAR FT`' C FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 1 40 AUTHORIZATION N OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 I 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 02/02 (Revised) Pre Iiltt 's:` ,DAVI&C0UNTI `H,EA6 %H DEPARTMENT Name " Environmental Health Section PROPERTY INFORMA IOIV P.O. B?x 848 Directions to property: / '� �` - Mocksville ryNC 27028 Subdivision Name: - — f Phnne` #: 336,751-8760 Section: Lot: AUTHORIZATION FOR ' WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# q 'AUTHORIZATION NO: 00268 A Ro d Name: ��t(1✓ N RGIZip: **NOTE** This Authorization for Wastewater System Constriction 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. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOb OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED r... l RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No L4 t COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SJATS" INDUSTRIAL WASTE: Yes or No �.�' LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �'LINEAR FT. r r OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: C.� FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: ✓ �/J/J' `� 1 �D F-1 � �� = ✓d AUTHORIZATION NO—A21– OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I 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 01/02 (Revised) NAM ADDRESS DIRECTIONS TO SITE DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) I'r�'GNE NUMBER 0�v''gT612 e SUBDIVISION NAME IV �i LOT # DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED / TYPE WATER SUPPLY C6 SPECIFY PROBLEM OCCURRING DATE REQUESTED 0/4 fvjo INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and �un'l6 SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. ,/93 I am responsible for all charges incurred from this application. z a I 2 v �� 11. &vllil