219 Crosswinds Dr Lot 6 ., r:;: ,. .:. f ...:,i.,a - .av _ry „n...:.�s; ., s1 � •;+•;r.! K ... .. � .. ti R .'�' i � .�
to
Pemictes's f �"�' DAVIE COUNTY HEALTH DEPARTMENT
'Name. e-ot i L1P`G Environmental Health Section PROPERTY INFORMATION I
r P.O. Box 848 �
Directions to property: L��� y f 1 0+� 'o Mocksville,NC 27028 Subdivision Name: ! A V C t''1 iy7c VT" __
k U A dC11IV C 1,Mone#:336-751-8760 Section: Lot:
o-�- AUTHORIZATION FOR Ql! f
I i G WASTEWATER Tax Office PIN:# �� V -
&
SYSTEM CONSTRUCTION
I IC( C/a5"SUJ'iAd --) 70&,o
AUTHORIZATION NO: 002953 A 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 1 I 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;r_T#OCCUPANTS_C1,GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY �f� DESIGN WASTEWATER FLOW(GPD) Q NEW SITE REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE Y F GAL. PU P TANK*GAL. TRENCH WIDTH ROCK DEPTH ' 11 LINEAR FT.q3`"'
OTHER eC^ 317
REQUIRED SITE MODIFICATIONS/CONDITIONS: .o
7WIL
IMPROVEMENT PER T LAYOUT v
v
L 0. C a L4 h—e
s <
+ — �4(Ii gni ja cJ
s
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
S STEM NSTALLED B Vh b Q
� o
.9
U
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOI HA 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)
Pettea's %,. �/ DAVIE COUNTY HEALTH DEPARTMENT
GjI'I if G Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
r Directions to property: Lkl i c `' Mocksville,NC 27028 Subdivision Name: `-
+� 6
#
Aone : 336-751-870
Section: Lot: p
AUTHORIZATION FOR [
A r Q t t 15 ( �f� I l Ci r7 C��V t i�t ,�(ry �j (G WASTEWATER Tax Office PIN:#
5 SYSTEM CONSTRUCTION
jj IC( C 1 U 5-5 JJ,Ad, .J
AUTHORIZATION NO: 002933 A "' Road Name: Zip:
**NOTE**ThisAuthorization 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)
�� 0C*,**NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
I IS VALID FOR A PERIOD OF FIVE YEARS.
E—VN IIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE - #BEDROOMS #BATHS�r%� #OCCUPANTS GARBAGE DISPOSAL:Yes or No `
COMMERCIALrSPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
6k
LOT SIZE tl/ TYPE WATER SUPPLY�D DESIGN WASTEWATER FLOW(GPD) I✓ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE t'- X GAL. PUP TANK�IVAGAL. TRENCH WIDTH ROCK DEPTH LINEAR
OTHER 4 (C 3).7 r cd
REQUIRED SITE MODIFICATIONS/CONDITIONS: +
:o
z
IMPROVEMENT PE TLAYOUT.
+- t
6L C C U 1/14 C, � u `(-t= 01A s c Ct I'/,g � 3
41
N
J.
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
V.
AUTHORIZATION NO. k 53 OPERATION PERMIT BY: Q✓ DATE:
**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 02102(Revised) f `
DAV&COUNTY ENVIRONMENTAL HEALTH SECTION
,r APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) G
NAME �1� N PHONE NUMBER
NC z110ak y�l� mangy
ADDRESS � �/ l'��i SUBDIVISION NAME
LOT#
7' 12 1 sir/ A t o les 6Z
DIR CTIONS TO SITE � �
AME
o�SYSTEM INSTALLED "! AME SYSTEM INSTALLED UNDERAt1,
TYPE FACILITY-46 -e NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY J.AZ-AIFSPECIFY PROBLEM OCCURRING ///✓ A21�
DATE REQUESTED "O 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 responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND `CERTIFICATE, OF. ZOMPLET,ION
'NOTE: Issued in Compliance with G.S. of'North Carolina"Chapter 130 -'Article 13c .',
Sewage Treatment and Disposal Rules10 NCAC 10A".1934-.1968) Permit Number
.Name
Location
,
Subdivision'Name' N TUN Sec. or'Bloc k'No.
---F- ,_
Lot Size �ra +"1`' House Mobile,Home._. Business Speculation
No Bedrooms ` No. Baths " No. in Family
Garbage.Disposal YES. NO..p
Specifications for System:
Aute�Dish Washer. YES.W , NO,❑ ;_ - GIQ .ea - art
Aufo Wash Machine YES NO:fl
r.
r
Type Water Supply
'This permit Void if sewage system described:below is not-installed within 36 months from date of issue.
h--- -L.
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'Numbe.r: 704-634-5985.
Final Installation Diagram: System Installed by� �!�� -7
Certificate of Completion ! Date ��
'The signing of this certificate shall indicate that the system described above h 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 of time.
.. _. ._ ,.,:,,�v-:..--.mow-.y..a,,,,.,y.—..,..amu:.<.Lu*•A.;Ycr ... t:._.w..vfi"k: +.. ;i.�. . .....�.. ,a �:3..++ve..0 1.:r.,a,:, .,.r.�.. o' .., r . ., r , .. -„... ,..
DAVIE COUNTY HEALTH DEPARTMENT
r, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name \ Date
-
Location r�c;, _
Subdivision Name Lot No. Sec. or Block No,
Lot Size l House ✓ Mobile Home _ Business Speculation
No. Bedrooms �_— No. Baths = \` No. in Family
Garbage Disposal YES NO ❑
Specifications for System:
Auto Dish Washer YES 17, NO ❑ – ,/ Do
Auto Wash Machine YES ,NO ❑ it
Type Water Supply (.� -,. nom.,
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
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 Z/
t
C
Certificate of Completion — Date
'The signing of this certificate shall indicate that the system described above h s, 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 of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 C►
Mocksville, N.C. 27028 C ��
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By �9�dry -�A�i�s �yy�y� Business Phone 773' 9P5'8
2. Address
3. Property Owner if Different than Above s ,Lo7 7°1� y,�,�,�>P ��,- C iol�lye
Address
4. Permit To: a) Install Z Alter Repair
b) Privy Conventional -'- Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
Industry Other
b) Number of people`7�I_ee
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 431C.3�
i
Bed Rooms Bath Rooms1�2 Den w/Closet D
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes g urinals garbage disposal
lavatory 11 showers 3 washing machine
dishwasher sinks
8. a) Type water supply: Public_P Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions -;t X40 X$dy -��159c.pEs)
b) Land area designated to building site 4�;'�`'2P5
c) Sewage Disposal Contractor Z-22
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
.�—'-2� `= ter-Le_ _ G�z1�
Date O ner eignaturd
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
� U
ti IV Ln
n-
a coilwe2 ! j > oL
1 �f �-1our.e I�af '—
� I
1-90
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section,P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
4ArG17in0..T h' �s//�.�Iv ,UCE�Zf 6 ' (office use only)
no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system. .
ye no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
G 3
DATE SI NATU E
4. 1 hereby authorize the Davie County Health Department to release site
evaluation res9s,from the above described property to the following:
Owner only
— Owners designated representative
Anyone requesting results
— Only those listed below
DATE I ATU
DCHD(11/84)
4
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Bax 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size A
FACTORS AREX 1 AR AREA 3 AREA 4
1) Topography/Landscape Position 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
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils �}� PS PS
U U U U
4) Soil Depth (inches) S S
(-DP 9 PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS
Tj U U
External S S S
C25---_ PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
lP� PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by - Title Date6:-3
SITE DIAGRAM
1
C�G
DCHD(6-82)