190 Tittle TrailPermittee's�--, DAME COUNTY HEALTH DEPARTMENT
S -
Name: � �`'�j' ` ,, Environmental Health Section PROPERTY INFORMATION
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 - -
AUTHORIZATION NO:4. ZiA Road Name: R' 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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMSI.a # BATHS -f-5' # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
(/ S S�
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SI
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� > ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"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 (336)751-8760.
I OPERATION PERMIT
SYSTEM INSTALLED BY:
ft� 5) ot&,
AUTHORIZATION NO. 61VOPERATION 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)
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
Sewag Treatt and Disposal Rules (10 NCAC 10A .1934-.196/8) p/ Permit Number
Name _ Date Q (o' 4
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size 1__ House —_lef!!�: Mobile Home _ Business __ Speculation
No. Bedrooms No. Baths_ No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ ����`^ ���/
Type Water Supply
'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:
Q�
System Installed by ( 4
.`ov e4a
Certificate of Completion 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 of time.
A
1-2
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address �
3. Property Owner if Different than Above &9hee?_7-
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional.Z Other Type
Ground Absorption
Home Phone ?9?- 3F -9W
Business Phone1e, 3 -4- - 356.1 �rTa�ov
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms __3 Bath Rooms_ Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 ho
7. Number and type of water -using fixtures:
commodes a urinals
lavatory
showers
garbage disposal
washing machine 1
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes 1-1"' No
9. a) Property Dimensions /9,5' Ac.PEs
b) Land area designated to building site _ Aeen—,
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? Ali)
This is to certify that the information is correct to the best of my knowledge.
Date Owner Sign ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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I-Ykl , 65 D // i l C'A SL E �e,Po s S rid E - Fa
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DCHD (6-82)
Name—
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1 ARFA 9
Date /Ar k1"�
Lot Size ely'12
ARFA R AREA A
1) Topography/ Landscape Position
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8)
9)
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PS
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PS
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2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
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U
S
PS
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PS
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3) Soil Structure (12-36 in.)
Clayey Soils
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PS
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PS
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1) Soil Depth (inches)
P
S
PS
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PS
U
U
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i) Soil Drainage: Internal
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P
U
S
PS
U
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PS
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External
PS
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PS
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PS
U
Restrictive Horizons
Available Space
PS
U
S
PS
U
S
PS
U
S
PS
U
Other (Specify)
S
PS
U
S
PS
U
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PS
U
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PS
U
Site Classification
-
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title
1j,
Date
rt�`I (vultAwIt tau 4 SJ y 4,:, do Irnwf
NAM
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APR�ICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER
ADDRESS I_U / SUBDIVISION NAME
Y n ti ,� �� LOT #
DIRECTIONS TO SITE (o 0
-1-aA-
J-X,
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER��,m �a✓t.�-
TYPE FACILITY At - NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �SPECIFY PROBLEM OCCURRING
DATE REQUESTEINFORMATION TAKEN BY2�:
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 F�� /If
Hev. 1/93