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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 �l DCHD(6-82)