197 Haywood Dr Lot 3• _ DAVIE COMITY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
I'VROVEMENT PERMIT
e*NOTE#* This improvement permit DOES NOT authorize the construction or installation 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 o
(In compliance with Article 11 of G.S. Chapter 130A, Wastewa r Systems, Sectio aqeTreatment and Disposal Systems)
NAME r PROPERTY AD 15
LOCATION / 7 / ,,en!II 1 /von C/ V --r,
SUBDIVISION NAME �/�i %/,iu� Aior LOT NUMBER
RESIDENTAL. SPECIFICATION: BUILDING TYPE # BEDROOMS _.L # BATHS
r
a 7 t7 6 6 DATE
SEC./BLOCK NUMBER ,2
# OCCUPANTS _�/ GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY.TYPE fes' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY F r,' DESIGN WASTEWATER FLOW (GPD) TE REPAIR SITE J
4
SYSTEM SPECIFICATIONS: TANK SIZE 1MV GAL. PUMP
.,/tANK A,* GAL. TRENCH WIDTHNROCK DEPTH ,� �LINEAR FT. �
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
m*THIS PERMIT IS SUBJECT TO (EVOCATION IF SITE PLANS OR THE INTENDED USE CHANE. YOUR WASTERWATER SYSTEM CONTRACTOR MIST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.,
�lfl 14/a&l r
�J P �
,s41 , �4
WO
4
/133X��
IMPROVEMENT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OpERATIDfiI PERMIT �.i T� SEMNSTALLED BY -
fl
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 10/95
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPS `PERMIT �.
**NOTE** This improvement permit DOES NOT authorize the construction or installation 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 _a-bdTdfn"ermit`
(In compliance with Article 11 of G.S. Chapter 130A; Wastewat r Systems, Section-=19Treatment and Disposal Systems) {
NAME PROPERTY ADDRESS r. a �I D O DATE
LOCATION / , /fi�irl lye j t/
SUBDIVISION NAMES �- % ., �.r� LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE ✓, .lrr # BEDROOMS #BATHS # OCCUPANTS GARBAGE�DISPOSAL: Yes/No
a
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY �_ DESIGN WASTEWATER FLOW (GPD) NEW MITE REPAIR SITE
q SYSTEM SPECIFICATIONS: TAN)( SIZE n,I0 GAL. PUMP TANK Ar -0 GAL. TRENCH WIDTH' ROCK DEPTH �� LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
..
" THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
**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 (704) 634-8760.
r
OPERATION PERMIT �=; rJ%' "�C� i^ SYf:TEM`1kTALLED BY /✓I/ ✓.Li6.�.c
15
:j
AUTHORIZATION N0.OPERATION PERMIT BY !✓ro DATE AA
**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 136A, 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 -10/95
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.***
AUTHORIZATION NLYBER
NATE ��//% /� Y /4� f DATE f, 1i U
NATE ON IMPROVEMENT PERMIT (If different than above) /1444/—�
SITE LOCATION J �7 !�!�, '/��n� el eOr t j V1 E AJ ffi/CM S.j7—
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
,3T
A 't DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'*OTE: issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sqwage Treatment and Disposal Rules (10 NCAC 10A .1934-.19a 8) Permit Number
Name
Date N2 6 476
Location
Z,
Subdivision Name. Lot No. Sec. or Block No.
Lot Size s..e �26 House Mobile Home Business'- Speculation
No. Bedrooms No. Baths I No.in Family
Garbage Disposal YES NO 0 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.
Em
*Contact a representative of the Davie
9:30 A.M. or 1:00-1:30 P.M. on day
Final Installation Diagram:
4
9
I�
Improvements
'ounty_HeEi WIT'be-p-artment for fins
completion. Telephone Number:
System Installed by
Certificate of Compn
'The signing of this certificate shall-indt a e that the system descri4e-d above has I
the standards set forth in the above regulation, but shall in NO -way -6e taken as a gua
satisfactorily for any given period of time.
on of this system between 8:30-
f1 L I � - -n-
Date
installed in compliance with
a
, that the system will function
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Z_fiome Phone 9 d'`�3�
✓ 1 ermit Requested By / e S usiness Phone %Z 3—
ddress ��� Z Afo-o .rfsz �as� fig.✓
3. Property Owner if Different than Above �X ay 4e s - /-0- V ,
Address
4. Permit To: a) Installsef!:'_"Alter Repair/
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House obile Home Business
IndustryOther
�) Number of people
a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms %--? 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 hours)
7. Number and type of water -using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public y/ / Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Name_
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 6QIV� ' J
Lot Size
FACTORS ARFA 1 ARFA 2 AREAS ARFA 4
1) Topography/ Landscape Position�
S
S
S
(.:°
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
110?�
U—UNSUITABLE
Recommendations/ Comments:
Described by --!l,1/
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Date
c
• A#
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 RECEIVMMAR 1 4 1989
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 91q 5;o'
�` 9
1. Permit Requested By 1%_J'k�',&e Business Phone 9/ P-2
2. Address :� C3 40,4 a S ci / "e- J✓L C_ 1
3. Property Owner if Different than Above G
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption 1�-�
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. ay If house or mobile home, state size of home and number of rooms.
House Dimensions --E 2'
imensions E7, X 9
Bed Rooms_ Bath Rooms 3 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)
7. Number and type of water -using fixtures:
commodes urinals garbage disposal 1
lavatory 7 showers a- washing machine J
dishwasher J sinks I ;�F , T� % 3
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions A G ?- E 't ->Z.�6 -5-20 ; & y 21f7 . PS—
b) Land area designated to building site
c) Sewage Disposal Contractor 5a2&-Zr
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 rr t to t e best of my knowledge.
Date Owner Signatu
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
� :
ADt �, 19
f'79- 3a()7
DCHD (6-82)
i
• DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie Cd my Health Department.
2. Carefully follow the procedures as outlined in the enc sed "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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
es no 1. 1 am he owner of the above described property.
yes 2. 1 am not the owner of the above described property, however; I certify that
have consent from a- I es , owner to obtain a
owner' e
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
y!�s 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.
NAT
4. 1 hereby authorize the Davie Cou-n*'tSr Health Department to release site
evaluation results from the above described property to the following:
— Owner only
Owners designated representative
anyone requesting results
— Only those listed below
DATE SIGNATt RE
r
DCHD (11 /84)
3
4 O
J NG
�i�fiJJ � j� �•.;
1 �1 5„ :qr kj y..�• + 7 r ,kk '.. SS J�. :. Tr
•`�' \ 1 JLv� 'L L '�af�.f�� � d � �1 4 4�y� "I ��� �� T
N } �t
4.1
ry
�,, ram:���t�> — � `*: .�r,f�• N
a ,: �1j� - rho' {{ '4,._• � 0 y a k.
to �',,•,,i�;�� �1 a� ��'�•�� � 9�,,,�..,.--��*�• h•
.�'�� � ,, � • -� � 5 �3 •x.,11�, 3 .
Irk
30.4 304
•s� .L4
co
rim
c
•A#
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 RECEIVMMAR 1 4 1989
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By�i��ri-e S LQ �a- l r�• „ '/4 Business Phone 9/y-AA li �l^9
2. Address C3 0 A a 1� /%e r cs- J�' iU�����i r7`e ,, .S•e. / J✓L ' �o-�
3. Property Owner if Different than Above G
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption 1�-�
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. ay If house or mobile home, state size of home and number of rooms.
House Dimensions--E 2'
imensions E,,X 'g 9
Bed Rooms_Bath Rooms 3 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)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal 1
lavatory 7 showers a- washing machine J
dishwasher J sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ���,
b) Land area designated to building site
c) Sewage Disposal Contractor 5a2&-Zr
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 rr t to t e best of my knowledge.
Date Owner Signatu
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�:
ADt �, 19
C' " - .r .a7o &�
9'79 - 3� e9
DCHD(6-82)
1
• DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie Cd my Health Department.
2. Carefully follow the procedures as outlined in the enc sed "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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
es no 1. 1 am ZeNo7niper of the above described property.
yes 2. 1 am not the owner of the above described property, however, I certify that I
have consent from a. Ze-s , owner to obtain a
owner' e
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DAZT KE NAT
4. 1 hereby authorize the Davie Count Health Department to release site
evaluation results from the above described property to the following:
— Owner only
Owners designated representative
anyone requesting results
— Only those listed below
DATE SIGNATt RE
r
DCHD(11/84)
• DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
t P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS PS
U U U U
8) Other_ (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6-82)
• _ DAVIE COMITY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
I'VROVEMENT PERMIT
**MOTE#* This improvement permit DOES NOT authorize the construction or installation 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 o
(In compliance with Article 11 of G.S. Chapter 130A, Waste.-C-4. r Systems, Sectio a Treatment and Disposal Systems)
l I �
NAME r PROPERTY AD SS d ib Y' a 7 DATE
LOCATION
SUBDIVISION NAME �/� i �/,iu� �.�I�<t LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL. SPECIFICATION: BUILDING TYPE # BEDROOMS _.L # BATHS # OCCUPANTS 4 GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION: FACILITY.TYPE fes' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY F r, ' DESIGN WASTEWATER FLOW (GPD) � � NE! ITE REPAIR SITE J
� 4
SYSTEM SPECIFICATIONS: TANK SIZE 1MV GAL. PL)M.,/tANK A,* GAL. TRENCH WIDTHNROCK DEPTH ,� �LINEAR FT. �
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
m*THIS PERMIT IS SUBJECT TO (EVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MIST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.,
h/ Aeafill
c Y
S - 15
xx
IMPROVEMENT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
AERATION PERMIT �.i T� SEMNSTALLED BY -
fl
ti50v�'o�i�
AUTHORIZATION NO. & OPERATION PERMIT BY DATE
*#THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIM 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 10/95
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPS `PERMIT�.
**NOTE** This improvement permit DOES NOT authorize the construction or installation 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 _a-bdTdfn"ermit`
(In compliance with Article 11 of G.S. Chapter 130A; Wastewat r Systems, Section-=19Treatment and Disposal Systems) {
NAME PROPERTY ADDRESS r. a �I D O DATE
LOCATION / ,/fi�/rl lvn_j t/
SUBDIVISION NAMES �- / ., �.r� LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE ✓, .lrr # BEDROOMS # BATHS # OCCUPANTS GARBAGE�DISPOSAL: Yes/No
a
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY �_ DESIGN WASTEWATER FLOW (GPD) NEW MITE REPAIR SITE
q SYSTEM SPECIFICATIONS: TAN)( SIZE n,I0 GAL. PUMP TANK Ar-0 GAL. TRENCH WIDTH' ROCK DEPTH �� LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
..
" THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
ol// Xcr if/ i " �/ �`
"... : Pe rid
f' • � cb4
_.._ IMPROVEMENT PERMIT BY11� 4
**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 (704) 634-8760.
r
OPERATION PERMIT �=;rJ%'"�C� i^ SYf:TEM`1kTALLED BY /✓I/ ✓.Li6.�.c
:i
AUTHORIZATION N0. OPERATION PERMIT BY !✓ ro DATE AA
**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 136A, 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 -10/95
• Davie County Health Department
•• ENVIRONMENTAL HEALTH SECTION D
• P.O. Box 665 ,
Mocksville, N.C. 27028
} AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
i
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.***
� AUTHORIZATION NUFBER
NATE DATE �� i U
NATE ON IMPROVEMENT PERMIT (If different than above) ` 9
SITE LOCATION J�7 !�!�'&-m, el �r /1//,# ril V1 f—AJ 9M-'5.j7—
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*"NgTICE*** THIS AUTHORIZATION FDR W ATR SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONNENThL HEALTH ALIST DATE.
DCHD 10/95
• APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Z_Home Phone
✓1. ermit Requested By / e SBusiness Phone 7-2 3—
Address ��� Z �o,o .y�sz �as� fie,✓ �'- 70/F
3. Property Owner if Different than Above �X 0y 4e s 134, /-0-V-
✓�-
Address X9-2/ f�iza�ic�odd 02L- Gt/.:rs �.�— Sa/�, 1!�'- 7/0-3
4. Permit To:a) Installsef!:'_"Alter Repair/
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House obile Home Business
IndustryOther
�) Number of people
a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms%--? 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 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public y//Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
L2
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Qox 665
Mocksville,N.C. 27028
SOIL/SITE EVALUATION r
Name ` < Date l��t�/✓/�
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS S S
(:k PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS PS
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification 110?�
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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DCHD(6-82)