287 Yadkin Valley Rd Lot 5 I ,
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Dale ou 4 Health Department
his j� nmental Health Section
0�1 P.O. Box 848
� '
210 Hospital Street
Courier# : 09-40-06 1911
Mocksville, NC 27028
Phone:(336)-753-6780 8� ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753.1680
(Check One) Replacement Remodeling Reconnection ea(( whit\ cokok
Name: c.��� (J � Phone Number 6 �Z�� (Home)
Mailing Address: Z�6� ��V+� �L�,L� 6 ��Z �j4�� (Work) W
J ON C-cz C-- Email Address: C-1LC V-A'cz� A 071- C C1�✓"�
Detailed Directions To Site: Ge-94,Z--- -�_S�Dz
Property Address:
Please Fill In The Following Information About A The EXISTING Facility:
��CL 1" VS I"n-- -Type Of Facility:
Name System Installed Under:
Date System Installed(Month/Date/Year): Number Of Bcdrooms:__7�>_Number Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes Go) If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: A 4.A(S-C-7- Number Of Bedrooms: Q Number of People
Pool Size: Garage Size:l-!-� C, Other:
Requested By: O)a Date Requested: C3 U
(Signa re)
For Environmental Health Office Use Only
pproved Disapproved
ents:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # ount:$ Date: s
Paid By: � i��eiBy:
Account#: 61b A ��`', n In ce#:
DAVIE COUNTY HEALTH DEPARTMENT r
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION (/QI,
*NOTE: Issued in Compliance with G.S.of North Carolina Chapter 130 Article 13c V
e a Tr atment and i posal Rule (10 C 10A.1934-.1968) Permit Number ��
/r J1 'Cv
. n..,
Name � l/ �L ate s<< 31�7
Location
w Q � .
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 E] NO,p Specifications for System: 1
Auto Dish Washer YES ❑ NO p p00 �G
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.
i
I l
Improvements permit by
*Contact a represent f the Davie County Health Department for final inspection of this system between 8:30-
9:30 A. day of completion. Telephone Number:704-634-5985.
Final Installation Diagram: �1 System I leJ(jir�,by J
/�+-`
,i
Certificate of Completion /r I'� Date 26 t
'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. i
FORIZATION NO: U 7 U 5 DAVIE COUNTY HEALTH DEPARTMENT E
ti Environmental Health Section PROPERTY INFORMATION
Permlteets P.O.Box 848 , �
Name:. -��uSQ� Mocksville,NC 27028 Subdivision Name:
1� / Phone#:704-634-8760
Directions to proper��i�,!t/ " r Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTION
Road N�me: L� P
**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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systerns)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
ENVIRONMENTAL HEALTH DATE I IS VALID FORA PERIOD OF FIVE YEARS.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS --5—GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION:FACILTrY TYPE #PEOPLE - #PEOPLF/S= #SEATS INDUSTRIAL WAS . es
No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE AII2 SITE '
SYSTEM SPECIFICATIONS:TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH��ROCK DLINEAR
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: `\•^\
� L
IMPROVEMENT PERMIT LAYOUT
K►l'�t
�ailer(
**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)6348760. f
1
OPERATION PERMIT
SYSTEM INSTALLED BY:
i
S ,V,
AUTHORIZATION NO. OPERATION PERMIT BY:_�// '(IIIc// 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 05/96(Revised)
I
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AUT .ORIZATION NO: 0705 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permtteeis P.O.Box 848 ` ,C
Name: �QGI Sr?r Mocksville,NC 27028 Subdivision Name: !� !° /
Phone#:704-634-8760
Directions to prope �!/ Section: . Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION H -
Road'Nae: G _
**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 11 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 ISSUEIS
� y;,_ ��eT is �f i�-T b" F . r A -3 T .•'•«,,..t .- - ,� -- .. ..-Y i. < .c�.t ' y -
..M'� �x r° Gc•.• `�" c ..y. ir rmi, �t;.:r'? ,.,:ti,. r. :s �nT�• �.
z OXO~
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT.AND OPERATION PERMITS PROPERTY INFORMATION
Pef'm .�'
Name-:
—� Subdivision Name:
i Directions to propeAy:• � Section: Lot:
i , r IMPROVEMENT
` PERMIT Tax Office PIN:#
Road�Name•VA6
**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 of a building permit
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
ff ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE _ #BEDROOMS -0 #BATHS #OCCUPANTS -'5— GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE M-- GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH S��r LINEAR 'v
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: `\•, `� Lam' ju
Q (a
1
IMPROVEMENT PERMIT LAYOUT
72
**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)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. s OPERATION PERMIT BY: DATE: �C a
**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 05/96(Revised)
•' DAVIE COUNTY HEALTH DEPARTMENT
}* IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
a
PefmiFte*,S
Names '"I''t� A Prf,�5e f Subdivision Name: !
Directions to property:,�! f Section: / Lot:
f IMPROVEMENT
PERMIT Tax Office PIN:#
A '17
Road Name:
**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 of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
` ***NOTICE***TIM PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE 2Y #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE '` TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE L"'—"GAL. PUMP TANK GAL. TRENCH WIDTH `-3 6 �
ROCKDEPTH---�:9 Ir LINEAR N
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: ,\` \ �! Iv`0
l IMPROVEMENT PERMIT LAYOUT
sS;1 r
41
w� cilFcr� �a,
r
k,
4
st
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM f,,
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)6348760. ,r
OPERATION PERMIT t
SYSTEM INSTALLED BY:
vV A
i.
.b4
AUTHORIZATION NO. S �G�W/
O �OPERATION PERMIT BY: DATE: �
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I1 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 05,96(Revised)
. s
INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT
NAME a.u S e fz� PHONE NUMBER
ADDRESS -BO-4 TA4 SUBDIVISION NAME
�dY,
SUBDIVISION LOT #
DIRECTIONS TO SITE
5-I- D�u-tee- Z=zA
DATE SEPTIC SYSTEM INSTALLED lea z
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPECIFY PROBLEMS THAT ARE OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
DAVIE COUNTY HEALTH DEPARTMENT
`• 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
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 ,0.' NO,E] Specifications for System:
Auto Dish Washer YES E) NO ❑
Auto Wash Machine YES p NO p
' Type Water Supply _
*This permit Void if sewage system'described below is not installed within 36 months from date of issue.
rr.
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: �r1 System Inst-alled by
1-%— -
114+
'Jcp
Certificate of Completion ' ! -'+ Date A",
6
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section /U't
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISS W.
'-�// Home Phone 7,2
1. Permit Requested By A111 M1 F/ Business Phone 7q*0-6/7(e
2. Address 92Z &ANoN �4Vt. ri9STon —fAltm NG Z7/016
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional-mof Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Woo Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions yy 8 X_ Z 8
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 hours)
7. Number and type of water-using fixtures:
commodes 3 urinals garbage disposal I
lavatory showers Z' washing machine
dishwasher sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes ffNo
9. a) Property Dimensions Z(# VX 6'00 '
b) Land area designated to building site /So • X ISO '
c) Sewage Disposal Contractor J' R` 7-4j/:✓ Ciu+'/ iT�eAcToR
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? //cam
What type?
This is to certify that the information is correct to the best of my knowledge.
Date OwndWature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
_-110 6 , -ro s,R. 8d/— LIFT ToWA,Qds r2M/NI7VAI - o.v Vi/nk„y Vall,Ey
PROPLRry vN xf_FT /-�1pRoA �0D f� QRST �� S��C SrGn� — FX0,P6k'TV Z1.1VE
/VIARKeJ/ wl� �cfe rT sr�xc - �o-r s o SuAv - de/d boob �q io$
CORNERS ARF
S howl by DoWe
FA-ii on Totes&
' pR 4E
DCHD(6-82)
X= STRkif
y DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �))q �
P. O. Box 665 Vo
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name AeNzV;111-AP ,,w�.-j,V>il�- Ar-A 1A7 GA,P,P� d-�.w.✓ Date 2-/d -`/
Address - _�� °' a7! 7y� Lot Size
6 �Cr�1r�slH/� /'J! 27/OZ
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
® PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) C=-55 <TP PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils 4-jn7-> <fn> PS PS
U U U U
4) Soil Depth (inches) .� S S
Y
PS PS
U U
5) Soil Drainage: Internal S S S S
PS PS
U U U U
External S S S S
<fF!S> 0s) PS PS
U U U U
6) Restrictive Horizons qLW
7) Available Space S S. S S
&!�) CIS> 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 S=Provisionally Suitable
Recommendations/Comments: o2&,,,Z -- e �- 42&,p
.L Gum[--Q'CSa'"'�l�-�s.� lc:✓' G�-r.-�. /lwe� . "7�1��1x
Described by Title Pw- X&'&V leoz"i:t' Date
SITE DIAGRAM \34'11e-1 Re«•4
At S o
,p •
� 3
2 'F-At ?
DCHD(6-82)