391 Madison Road Lot 3'J V.K(7
.iJiHbRIZ.ATION N0: ' fl DAVIE COUNTY HEAI TH DEPARTMENT
!/ Environmental IIealth Section PROPERTY IN17ORNINTION
Permrttde's/ / :A ,% P.O. Box 848 6/00
Name ' <�/' t <:J( !� n' Mocksville, NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property: / .� �i/'�i/.(„ Section: Lot: /17'
AUTHORIZATION FOR
WASTEWATER
✓ �/ / /. int./!. %s f ! Tax Office PIN:#'7 -
SYSTEM CONSTRUCTION ,/ ✓il nIS n
Road Name:)XA)9h!a0d zip:A'70�
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
-'7 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f<ii IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEAL V RPECIALIST , DATE ISSUED
W RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS - JI OCCUPANTS —GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION. FACILITY TYPES eggs # PEOPLE _ # PEOPLEISHIFT # SEATS _ INDUSTRIAL WASTE: Yes or No
LOT SIZE ^S TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE/ 4REPAIR SITE
SYSTEM SPECIFICATIONS:KSIZE iK--'_- GAL PUMP TANK GAL. TRENCH WIDTH �:: ROCK DEPTHS LINEAR Fnet'' Y /
, -' •'OTHER - l'[rfOr ��d'6'I'7i.Sr' �i'/4' .
i
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
A
**CONTACT A REPRESENTATIVE OF THE DAVIS 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. 11
OPERATION PERMIT --
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SYSTEM INSTALLED BY: FA449y f "Llbe
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50arv_z 1140 OFF PhLL
NO
AUTHORIZATION N0. 1WO OPERATION PERMIT BY' DATE:
-7 ITT
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY M DESCRIBED OVE HAS BEEN INSTALLED IN COMPLIANCE ... .
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATME AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -
DCHD 05N6 (Revised) - - -
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DAVIE COUNTY HEALTH DEPARTMENT
=- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Sanitary Sewage Systems p/ Permit Number
Name��%� /n ria DateZ-_-f^Cf No 6259
Location .�
Subdivision Name GIiPi, /S/ i Lot No. Sec. or Block No,
Lot Size f nr> House Mobile Home _ Business Speculation L�
No. Bedrooms __ No. Baths y No. in Family
Garbage Disposal YES ❑ NO p/
Specifications for System:
Auto Dish Washer YES4 NO El
Auto Wash Machine YES L _NO ❑
Type Water Supply
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
*Contact a representative of the Davie County Health
9:30 A.M. or'1:00-1:30 P.M. on day of completion.
Final Installation Diagram:
!Y
O
Imp r�gV mentspp jrmit by
rtm6nt for Aal inspectoiPA1'
this system between 8:30 -
Sy tem stalled by,
>a
f 11
U
ry Q U
a k
Certificate of Completion �Q 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.
NPPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ,
,P+ -sir,}, Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVED JAN 10 ft
Mockeville, NC 27028
1. Application/Permit Requested By "�Q ttt" Qx)Gmt&& [ O K) �tp� we
Mailing Address®
Home Phone Business Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above 'KLQi -:FPAW
4. Application/Permit For: C) General Evaluation S/Tank Installation
5. System to Serve: X House [) Mobile Home 0 Business
LL] Industry 0 Other 0 Unknown
6. If house, mobile home: Subdivision SOC)Q14'aRC)OLK Sec. Lota�y`�
No. of People Dwelling Dimensions
No. of Bedrooms— Basement/Plumbing
No. of Bathrooms % Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No.
No. of Commodes No.
No. of Lavatories No.
No. of Showers
of Sinks
of Urinals
of Water Coolers
S. Type of water supply: Public 0 Private p Community
9. Property Dimensions _ loo k 0-00
10. Sewage Disposal Contractor
11. Do you anticipate additions/ e pansions of the facility this system is
intended to serve? D Yes iNo
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to trice
best of my knowledge, and I understand I am responsible for all
char es incurred from this application.
Tu0
Date Signature
Cn n I k) n io-r k4 --Cn Feil l e o L) '9-r)
to Property:
.o
DCHD (10-89)
DAVIE COUNTY HEALTH -DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
`l y 'Z-�
Date `
3
-'9 2
PS
Address
'9'
Lot Size
U
sem, d�
U
U
FACTORS ARFA t ARFA 9 ARFA 3 ARFA A
tj Topography/ Landscape Position
6)
8)
9)
S
S
PS
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
(0
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
a7�
S
S
PS
S
PS
U
�j
U
U
3) Soil Depth (inches)
S
pS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
PS
S
PS
lT
U
U
External
PS
U
PS
U
S
PS
U
S
PS
U
Restrictive Horizons
Available Space
S
S
S
PS
S
PS
U
U
Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
Site Classification
/-C.
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: e °� 4Q1
Described by -s Title Date
SITE DIAGRAM
1a f�
oti
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.100
DCHD (8.82)
Davie County Ykalt,6 rD�eparhnenf
and Noine NealK ✓ty'ency
210 HOSPITAL STREET/ P.O. BOX 885 -
MOCKSVILLE. N.C. 27028 - -
PHONE: (704) 634.5985 -
April 23, 1991
Potts Realty
.Attn: Diane Potts
P. 0. Box it
Advance, HC 27006
Re: Sewage System Installation
Stonybrook/Sec. 1-Lot.3
Dear Realtor:
The septic tank system that serves this residence was designed,
inspected and approved by this office on April 18, 1991.
With proper maintenance and use it should function properly.
Sincerely,
Charles E. Little, R.S.
Environmental Health Section
CL/wd .
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