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1859 Yadkin Valley Rd �..� ,, -,:�:;.,,_ r:•-r . . �`• . ..}:,-a>-_-�_ . . _:.x __ . -,...e . - . . .., -. - , . � . �- - r -,;;_ . . ,� -.,.., . .._ _.,:,�.._.. .. _ . , � i..«�; •�4' 7-� .r' ..a "'i'. .. .. } . . . . : , .... .. _ ..,.-, ��:-• ;..,. C..�e , ,AU�'H�P,IZATION NO ': •� �' •�. DAVIE COUNTY HEALTH DEPARTMENT � �— �--�'�— � � # � � � ---' Environmental Health Section PR PERTY INFORMATION Permittee's��{'', i _'� P.O. Box 848 Name: ! :��-�'��f'� `"'�-��' Mocksville,NC 27028 Subdivision Name: �f, � t��►� Phone# 336-751-8760 Directions to property: r�.t1� � Section: Lot: � AUTHORIZATION FOR �f i �,,,)t^�� WASTEWATER " G�'�"'�"� �� N"'�`'"�'� �r� � � SYSTF.M CONSTRUCTION Tax Office PIN:# - - , .f r,, i , ,� �,, � �,,,�`� , ,f j� � t�� i`i•-C.�x ,.'� �� t, �� :1-I�a�1 LC.:.a {�f;t�Sv Road Name: �,°,c�k.�a VAL�.t::.`f Zip: `��:G(r. **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 Forni/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. , (ln compliance w'th Arti le l l,of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �`, j -ti; ��'' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION S� if :l'`� 'n�'��r� `� ''.`� U:�- IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRO1CfM N ��jfiEALTH SP F�CIALIST DA E ISS ED / , _ , , , . � . < . � - ( . . .., �.. ,, i. � al ` r , . 7:?,� . :«�,:,,�,i--'R� " 4 � ;;; ��DAVIE COUNTY HEALTH DEPARTMENT e� �- :-� '�-- ,.,.r.•,---• TMPROVEMENT AND OPERATION PERMITS PR PERTY INFORMATION Perm,ittee's�' \, �.�;, . r ,_ �-pName; � t-:�-_ f'`�. f'`� �'�.��=r' Subdivision Name: .� F '.. � Kt .. . Directions to property: °. i M 1`�' 'r"��'�"� Section: Lot: IlVIPROVEMENT �,'t',i.� � �° 1�t�, :, �-u;•;.4.��` ii�:� - . PERMTT Tax Office PIN:# � 'r � �! �r�v.� t .� � �"` � r�� 3�.�t': �.� . ��i;=�c1 �� Roa�Name �{� ��_f ii�i�..::�`� �Zip; %+- **NOTE**This Improvement Pemut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An AUTHORIZATION FOR WAST'EWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �„- / � >� � � ! ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE ,'�p i �% f ".�` , '" "�. �-; �;�{. ;,:.. PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER �ENVIRONMENTA�I-IEALTH SPECIALIST DA E ISS JED SYSTEM CONTRACTOR 1VIUST SEE T'IIIS PERMTT BEFORE 1 INSTALLING TI�SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE FIOt?S f#BEDROOMS � #BATHS (.'ST #OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE� �"�% TYPE WATER SUPPLY ��/DESIGN WASTEWATER FLOW(GPD)�� NEW SITE REPAIR SITE''� ri �, SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `�� ROCK DEPTH � �-- LINEAR FI'. �R�' OTHER � ��j�� t�11 E�-� ��GX REQUIRED SITE MODIFICATIONS/CONDITIONS: ��L�=� ""�� v" ��-=� ^�� -�� u ��--� j�'�.�p,k IMPROVEMENTPERMITLAYOUT'�W�'t�ROVED EFFLI1cPd1� FILTEF��: �"+'}Z1+�'7i��.5'� 7� �� .d.-J FIE�IS}��D GR�P,`'��1:` `�� _,�__��...a,,....�.�., -��a��;,, �,o�� e��L �� F��-� � � � .�s�- , , . . . . . . . ^ F�' . . . , . . . ,k`;r . ,� �� . �°� � : � ( � �; r , �r�a **CONTACT A REPRESENTATIVE OF THE DAVIE C�UNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS S YSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS�75��'��. (�oG?75i-876�6 OPERATION PERMTT SYSTEM INSTALLED BY:__ L�'�`�'J� � �r��-S� I��. c:�� Fl1.aJ�' ,�, � ��{t2' �, � ,�,� �°° � '�l �� AUTHORIZATION NO.`�Cl�OPERATION PERMIT BY: DATE:� �v � **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TH S TE SCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S.CHAP'TER 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 OS/96(Revised) , _ `��'o —2:'�� . DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION � ' ' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) � ' � � ►�' �0 �� r NAME � PHONE NUMBER ' /A n^ �b ADDRESS I q �� /�tl.�L � �J SUBDIVISION NAME (`1 LOT # DIRECTIONS TO SITE 7 � r�- � DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER �IfiL lit� J � �+J I i►Al.l.`� �v►i�F � �.� TYPE FACILITY Ovc��! IZ7'Q UMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY W�� SPECIFY PROBLEM OCCURRING�� Q�� 1 DATE REG�UESTED INFORMATION TAKEN BY � � 0 This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible}or all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 ,f ' !A �" � �- � ' � � �� , .__ _ . . ._ .._. . . . _ _ . _ n�o�'"�J ��Q f�� 1'��Q"' j o' c� A 9�. 1�3 � ,� , DAVIE COUNTY HEALTH DEPARTMENT t`� �--- '�� ' 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 1',= ,�� • ` �<< �, Date ��' �� , ;, �_ .., � ,. , : ... ,. , , . ._ Location - �.� . ;� � �; �,��t-_ -� �� ,, -r � �=� ��,. � ` �_ y ` Subdivision Name Lot No. - Sec. or Block No. Lot Size `�� - '�� House `� Mobile Home _ Business Speculation No. Bedrooms � No. Baths ' No. in Family _ Garbage Disposal YES ❑ NO p Specifications for System: � � ' - `:, � `' ' , ,. Auto Dish Washer YES � NO � _ , , ,,, Y.;r� ,,, ., _ Auto Wash Machine YES ❑ NO ❑ `� � =~ f� - .� Type Water Supply E� ' , --- � � � _ `>i , � .� . , ; �� , . . . ,� � `j � ` � , `This permit Void if sewage system described below is not installed within 36 months from date of issue. � , .. �'� ,, . ' �`. , � '; ' \ �� '�� , � � ;� � � � rt__:�^:'� \ � i � + i ' ; i 'S � � \� \ . \ .,,\ � � � r_..- —� t� � � � rti � � . b\,,---`--� ',.� i �:( t�. i � i i` ; / ' I ; + fr ! Improvements permit by —';T`'' �`f�'`: '" `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�� ( �a,t�.�" �rn�-�-- ,ll�r� , � 3f�i�. �� . �'°x � k«�� ' ' ,� 5�►S ,�� , � �� Certificate of Completion • � Date lfl '"�7��" "The signing of this certificate shall indicate that the system describe 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. . ,_,, . ___ .._ .. .. _ _ . . _ ,: . „.,. _ •� _�� •c.1 , �� J�'.�� '� .'r , . - •. �" � , ' DAVIE COUNTY HEALTH DEPARTMENT : <<-` � _. "-_—.------ � � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ti '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 ��t� � �, � I, Date � -1� -%'�l P , �";:;,. . Location "�,1 I - l.� � t: ::� �� , ti�.._ __ ?�C,i - '1,1 �:,�_. !,^ �t - ��- >;,, �' �..�r �1... �— � Subdivision Name Lot No. Sec. or Block No. Lot Size � ��% �� • House `' Mobile Home _ Business __ Speculation No. Bedrooms � —_ No. Baths _ � _ No. in Family _ Garbage Disposal YES ❑ NO p Specifications for System: t :�:�-� �; �=' l ��%' Auto Dish Washer YES � NO 0 _ _ -� r��.:�y — ��>V 'l � ��1 ��..�,�G - . Auto Wash Machine YES ❑ NO ❑ �� l.�!i,� U �� - f�,. �<<, �, .. . . �� r, � .-. _ . Z Type Water Supply T�, ,"� --- ' `-, �. ! , . , *This permit Void if se�wage system described below is not installed within 36 months from date of issue. i,r ,. , � ,r.. . /` • . l �1 � � _ A � � . , V�_/ n/ / t) . -__! �_ ,� \1 � � � { � � ',, ,\� \ .\\\ � �!— �� i i-�.� �.��-� � v �'�� {I �Y! ! � ' Improvements permit by -�- �r� ��^� ``�• i "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 ��`'. i � .� , � .i_ =-.__�..�__ :ri��' �� , ,r- ,��;, ,' ` ,. , „ `y.�� ,.�'` �,,,lt�;. �`,.- � � :',� �,�Si x / � � F�� / > --i��-J-��/�` / � G.�{ � �� /�' / �—�� ` � �~� � a•``7? �--•. � �►�-��- � ��, � t.._._-_.____ Certificate of Completion �� `� `• � ' Date !�% - %% - '�"�f_ r,_._ _ "The signing of this certificate shall indicate that the system describec� 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. � �• ' ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name �A��L �'�� Date g� �� y Address Lot Size g '!i �,... FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S �-S� �S � PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S � S Loamy, Clayey, (note 2:1 Clay) r�P� � � PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS � � PS � U U U 4) Soil Depth (inches) S S S S PS � � PS U U U 5) Soil Drainage: Internal S S S S PS � � PS � U U U External S S. S S � � � PS � U U U 6) Restrictive Horizons ,,,�' Z�� o�`��, �y�„ p�• 3 7) Available Space � � S S � PS U U U U 8) Other (Specify) S S S S PS PS PS PS � U U U 9) Site Classification �j �S � U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments /d '�`� Described by ��"'� Title �- �� Date�� SITE DIAGRAM GL��oO� . �i �v � �a �3 GC.� � s I �h"```' DCHD(6-82) � ZS . - � . . ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section �� P. O. Box 665 �C�– Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. �ro, Home Phone 7�� r �7 �� '` �b� 1. Permit Requested By � � � �� Business Phone �� 2. Address �O l� � -�r SS�� 3. Property Owner if Different than Above S'✓�� Address � � 4. Permit To: a) Install Repair b) Privy Conventional Other Type sorption � �/ '`�d�� c) Sub-Division Sec. Lot No. ��CJ 5. System used to serve what type facility: House M�ome � Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms�—Bath Rooms Z Den w/Closet b) If Business, Industry or Other, State: Number of persons served � What type business, etc. Estimate amount of waste daily (24 hours) t 7. Number and type of water-using fixtures: commodes Z� urinals garbage disposal lavatory Z showers Z washing machine � dishwasher sinks Z 8. a) Type water supply: Public � Private Community b) Has the water supply system been approved? Yes No � /1/(� 7'� j�� 9. a) Property Dimensions � /Z �C�� S b) Land area designated to building site "�7 ��2 ,i.��✓� S c) Sewage Disposal Contractor -- 10. Do you anticipate any additions or expansions of the facility this sewage�s,Ystem is intended to erve? What type? l��/� �7� �/� � S C�?f/ — G� �L�� G�/i G G L� ��- This is to certify that the information is corr ct to th est of y kn wledge. ��/ O 7 �. •`�' __.---- , Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: � ��,.�� _ /�� .-�-t: �...�� , ��...�, �°`�'�`` � DCHD(6-82)