414 Liberty Church Rd (2),.r DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME M'i(Ai j L4,w.6 PHONE NUMBER L 2-- 22-
ADDRESSUBDIVISION NAME
M0 Gkb'v. t (.F Y1 L 2.70 ?.� LOT #
DIRECTIONS TO SITE 601 —N T• QE+ U hk4j d- F90 w,,l� w• f2'f'
DATE SYSTEM INSTALLED 9142— NAME SYSTEM INSTALLED UNDER LA v1.b
TYPE FACILITY� NUMBER BEDROOMS 01- NUMBER PEOPLE SERVED -3
TYPE WATER SUPPLY ('ou►^T SPECIFY PROBLEM OCCURRING Ca►My+c %• -Toe !!A roy-J
DATE REQUESTED 3-L -0 2- INFORMATION TAKEN BY
This is to certify that the information provided Is correct to the best of my knowledge, and that I understand I am Iesponsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
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tuTHpRizATIa1w A, DAVIE COUNTY HEALTH DEPARTMENT L
Environmental Health Section PROPERTY INFORMATION-- -•.. —
Permittee's r P.O. Box 848
Name: ��-IC� AmC Mocksville, NC 27028 Subdivision Name:
r
p - Phone # 336-751-8760
Directions to property: tGi)� I`% `fa �iir,+.I� ._ Section: Lot:
AUTHORIZATION FOR
4 Pvi)Jt WASTEWATER
SYSTEM CONSTRUCTION ` Tax Office PIN:#”
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Road Narrie� Lf l� �l) k`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 comp li_ ancri cle 1 :'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..•
0 ALTH PKi'AL ST DATE I SUED
w Ct�"r -=, �,,"- ' ��r lr1 I _fir .a ,,, q'e 1 . ,�' E:.. ._Y 3,_ � •y,,,. }. elf � ti l7, ` ._ 4 1;
DAVIE COUNTY HEALTH DEP RTMENT .t )
z IMPROVEMENT AND OPERATIO PERMITS PROPERTY INFORMATION
' Permittee'sLArr;
Name: i.. ►` Subdivision Name:
Directions to property: Section: Lot:
7 IMPROVEMENT C' ;
1d t– '!. if . f`..I 4 '01). S - �' PERMIT Tax Office PIN:# -
f Road Name: L. i i`t.l 4, `l i ` ZIP: r a'
i
**NOTE**,This Improvement Permit DOES NOT.authorize the construction or installation of a septic tank system or anywastewater system.'
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,�zticle 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
s f f'
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
o y, -"`— SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVflV6N' ENS, LHEALTii JPECIALIST . DATE I SUED INSTALLING THE SYSTEM.
_. 't, � �, y4„' • ': Via,
RESIDENTIAL SPECIFICATION. BUILDING TYPE 61\M Ft # BEDROOMS 2_ # BATHS -_-j # OCCUPANTS _ GARBAGE DISPOSAL. Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes orNo
Ile
LOT SIZE YPE WATER SUPPLY 1�11�Y� DESIGN WASTEWATER FLOW (GPD- fO NEW SITE REPAIR SITE 1
1
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH - ROCK DEPTH 17- ,. LINEAR FT.GCS
OTHER , L'Jt.L I -L%�-, I ✓l t F1 -rA)►l 03
REQUIRED SITE MODIFICATIONS/CONDITIONS:YA LL b 4 -VW Q _ v 1�e-� S C�r Y t Vt)►J Q i)11co
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER* *RISER(S) IF 611 BELOW FINISHED GRADE*
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTJJ ,YSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # I 6
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AUTHORIZATION NO. -F «- OPERATION PERMIT BY: A 251,
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA BOVE 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 05/96 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 130.
Permit Number
Name r'i-,r 3' >_.:,,,!> Date
Location I' ' ,' `�, :.' t —
Subdivision Name
Lot No. Sec. or Block No.
Lot Size / . House Mobile Home Business Speculation
No. Bedrooms No. Baths `= No. in Family L`
Garbage Disposal YES ❑ NO p- Specifications for System:
Auto Dish Washer YES p NO ❑ _.
Auto Wash Machine YES ❑ NO ❑ _
Type Water Supply r ---
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements 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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion %J-- Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period..,QLtime.
1
t
tir
Improvements 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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion %J-- Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period..,QLtime.
DAVIE COUIFTY HEALTH DEPARTI ENT
EIIVIR01411ENTAL HEALTH SECTION
SOIL/SITE EVALUATIOP
I?A1� /%%: L/ ��m� #,z I 3 DATE Z
ADDRESS V,
/%%a �,['Jv%/� , rv• � f'707- LOCATION
p- e G Ftia
LOT SIZE j acs e—
TOPOGRAPHYs
SOIL TE.,,TURE o S .-•
SOIL STRUCTURE. s �S y,.r
DEPTH: S
RESTRICTIVE HORIZOtISas _ �/o S.�oc�G� y,�l� �. �r _ �p •�
PERCOLATION PATE:
2 �..a9 r . w., l-� • 1.
(b, Nta 2- 9"91- 2.
c� sl.waa C _ 3.
Presoak
Hark & time
Drop
Time
Rate Yiin. Inch
fihp
G �r (`:4/1�
y
/0% z
(o, p�'f�!
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io; 2 c)
CLASSIFICATIOPI g
Suitable < CrovisLiorially Suitable Unsuitable
COM-4EIITS
SANITARIM
SITE DIAGP"