2503 Cornatzer Road Lot 2PrmtRee s DAVIE COUNTY HEALTH DEPAR ENT . //,-rep
Environmental Health Section PROPERTY INFORMATION'
as.a3 ,�� P.O. Box 848,
Directions to property: 4ii�rJ ? /,r %+Mocksville, NC 27028 Subdivision Name:
�!�ldflw�,r Phone #:. 336-751-8760
41 Section' f Lot:_
AUTHORIZATION FOR -
WASTEWATER Tax Office PIN:#
q C SYSTEM CONSTRUCTION - - - -
AUTHORIZATION,, 2 '1 5 O A Road Name Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pennits. This FornVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I I 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.' .
ENVIRONMENTALHEALTH 0ECIAI IST DATEISSUED -
RESIDENTIAL SPECIFICATION: BUILDING TYPE —11!9-4 # BEDROOMS �� # BATHS _� # OCCUPANTS 'AGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: 174�$ILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS _ INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE - - ' REPAIR SFPE
.. SYSTEM SPECIFICATIONS: TANK SIZE - - GAL. PUMP TANK —GAL. TRENCH WIDTH 76 ROCK DEPTH,yV_� LINEAR FT. /,Nf
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: -
**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.
AUTHORIZATION NO. OPERATION PERMIT BY: - DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T4T741B SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1l OF G.S. CHAPTER130A, 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.
Pe'rnnttee s �; y DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION ,
«� > P-6: Box 849,
Directions-to pro�� `�J / r r �:; %• F. /'Mocksville, NC 27028'' Subdivision Name:
+ � Phone'#;336-75I`8 60 "
«.d' f .r'.'.�t'•.+;fCr°''. i'k/ f':' , .. Section Lot:
AUTHORIZATION FOR • ` '
WASTEWATER
SYSTEM CONSTRUCTIONTax Office PIN:#
AiTTHORIZATION N0: 215 A " Road Name. Zip:
**NOTE** This,Authorization for,Wastewater System Construction MIJST'BE�,SSUED by the Davie County' Environmental Health Section prior
to issuance of:any Building Permits. This Foriri/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits. k
(In c o pliance with Article 11 of,G.S. Chapter 130A,: Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
"ti'/:� J".�a.✓�('L�'y1 •�' '- k l t i IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
7
RESIDENTIALSPECIFICATION: BUILDING TYPE _ # 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 ( G• .DESIGN WASTEWATER FLOW(GPD)"NEW '.REPAIR SITE
SITE—
SYSTEM SPECIFICATIONS: 'TANK SIZE GAL. PUMP TANK ' GAL TRENCH WIDTH �I ROCK DEPTH LINEAR FT..�2 '
`+ 'OTHER
REQUIRED SI4 MODIFICATIONS/CONDITIONS.
' IMPROVEMENT PERMIT LAYOUT
1
;l
r:
L
-**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)7i51 -S760.,:--'
OPERATION PERMIT
SYSTEM INSTALLED BY:
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Dko jievZ 0-(%-0(�. .
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I alk• I�p-� � `�C .
AUTHORIZATION NO. OPERATION PERMIT BY: �""�`� DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL' INDICATE TH ; E SYSTEMDESCRIBEDABOVE 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 MW (R.vi.M
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 CIO ctr ca li vww rc Date 3684
Location
Subdivision Name Lot No. Z Sec. or Block No.
Lot Size ��%✓zoo_ House L-- Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths 1�2 No. in Family
Garbage Disposal YES 0 NO fl Specifications for System: /�
Auto Dish Washer YES. p' NO E]_R i; _ ?oo ;Y3"eld"s'�c,K
Auto Wash Machine YES NO ❑
Type Water Supply CnA _
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
F
\ t3Z \x ;TZ L a- 0.--x.
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:
System Installed by
i f
Certificate of Completion Date
`The signing of this certificate shall indicate that the system described above has been installedinicompliance 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
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 Q- Z�1-�S� ��(? 3684
Location
Subdivision Name
S -k,
C., IS
Lot No. Z Sec. or Block No.
Lot Size Art //lZo
House r---
Mobile Home _ Business Speculation _
No. Bedrooms - 3
No.
Baths r i(L
No. in Family
Garbage Disposal
YES
❑ NO,g-
Specifications for System: J"'O
Auto Dish Washer
YES
NO ❑
g! _ 2 oW CA
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
Improvements permit by — ()A
*Contact a representative of the Davie County Health Department for final inspection offthis—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
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.
tr
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��� / i✓� .��/SYl/.d'PS Date r
Address sP �J Lot Size YcW2!�
FAr.TnRC ARFA 1 AREA 2 AREA 3 AREA 4
) Topography/ Landscape Position
2)
4)
5)
6)
S
S
S
S
PG>
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Sj� (note 2:1 Clay)
®
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
<±35PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
Sp
S
PS
PS
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
S,
PS
PS
PS
U
U
U
U
External
rs�>
S
S
S
PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
/r/o.Ye
Available Space
S
S
PS
S
PS
S
PS
U
U
U
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
—.l
;?r
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisio ally Suitable
Described by 2�1 ` //d� Title Date syl-E ?
SITE DIAGRAM
f
DCHD (8-821
EM
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested
2. Address
^ 1 Home Phone-
4JU 4314-C' "caw -d{ Zig Business Phone
3. Property Owner if Different than Above
Address
4. Permit To: a) Install I Alter— Repair—
b) Privy— Conventional ' Other Type—
Ground Absorption
c) Sub -Division- �_�AJJ Sec Lot No. 2_
5. System used to serve what type facility: House � Mobile Home— Business—
Industry— Other
b)Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
i
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:
1 commodes urinals garbage disposal X
lavatory showers washing machine
dishwasher ✓ sinks
8. a) Type water supply: Public ✓ Private Community—
b)
ommunity b) Has the water supply system been approved? YeS___.eITo-
9. a) Property Dimensions IVD
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 OvMer Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)