449 Madison Road Lot 8DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
_IMPROVEMENT PERMIT
✓x0
**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 it of S.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME ! Ol�iy///�/ O>7S / / PROPERTY ADDRESS Wd,OIStl/✓ 'A901 . —A 740AF DATE In/9E!
LOCATION
SUBDIVISION NAME �rfdJ!/�yl �/GYJ K LOT NUMBER _Y SEC. /BLDCK NUMBER
i
RESIDENTAL SPECIFICATION: BUILDING TYPE %.OufF # BEDROOMS �? # BATHS # OCCUPANTS _ GARBAGE DISPOSAL: Yes/No
COMMERCIAL SPECIFICATION:
FACILITY TYPE # PEOPLE # PEOPLE/SHIFT
# SEATS
INDUSTRIAL WASTE: Yes/No
LOT SIZE AWY"
TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)
NEW SITE
V/REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/�L GAL. PUMP TANK _ GAL. TRENCH WIDTH ��� ROCK DEPTH1z LINEAR FT. 7bQ
OTHER
REQUIRED SITE MODIFICATIONS/CDNDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WISTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY AIW //
**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.
OPERATION PERMIT SYSTEM INSTALLED BY
f
AUTHORIZATION NO. '0 3 5 O
IEE
OPERATION PERMIT BY CSO R� DATE la,1 (b
**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 ' 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
i W WO� t ism^' 4 �g sY�J 4't9(9i'YiIP'n,f A y -..'fA ..,�. • '. i. J '1 ri S Y :..Y-4 r.f .G ry1' _
% Davie County Health Department T
ENVIRONMENTAL HEALTH SECTION 2 V
r P,O. Box 665 'cJ
- Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
y
l (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.***
E %/ C ay✓S DATE S'o� ?-9G f N2 RIzaT0363
R
N
NATE ON IMPRGVEMENT PERMIT (If different than Jabove), / pZ
\ SITE LOCATIRIflOiSfl�i /� Y '., :. Sr6l✓�L/ O�L� /� �a T O
MM ENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
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APPLICATION FOR SITE EVALUATIONIIMPROVEMENTS PE U�
Davie County Health Department MAY _
Environmental Health Section MA
P. O. Box 665
Mocksville, NC 27028 ENVIRONMENTAL HEALTH
DAVI COU
1. Application/Permit Requested By II G
Mailing Address - `l W LIU Home Phone R? 9 �
t
Business Phone rA��
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve: 5LHouse
I] General Evaluation iNeptic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision �•4isn^•', Q3-"" _ Section Lot #
No. of People n
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions �ib �1 Jai -
6.
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers _
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Basement/Plumbing
.1& Basement/No Plumbing
(`Washing Machine
EE Dishwasher
❑ Garbage Disposal
7. Type of water supply: Public ❑ Private ` ❑ Community
8. Property Dimensions A�r Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑'Yes >1 11No
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.
FROPERIU INFORMATION REQUIRED:
Directions to Property:
Tax Office PIN: # f%f /60 A0 06 4
PROPERTY ADDRESS, as follows:
(2,U, Road Name: Mn(t,V
City: Yvur'� r9 rn 11911 V -0 -
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
This is to certify that the information provided is correct to the best of my
Incurred from this �applica_tjon.
DATE
and I understand I am responsible for all charges
t
SIGNA
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: J.1. I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary
anddispo sal system.
DATE
DCHD (1183)
E
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 4 - 13 -% I
Lot
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1j Topography/ Landscape PositionS
SPS
PS
S
S
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)lPS")
<
S
S
PS
S
PS
�
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
S
S
PS
S
PS
U
U
3) Soil Depth (inches)
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
PS
S
PS
U
U
External�S
� 0
S
S
PS
PS
PS
PS
U
U
U
U
I) Restrictive Horizons
Available Space
S
S
S
PS
PS
U
TI
U
U
i) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Q Site Classification
7
7,S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: r'6/
Described by - C� Title Date - D -�
SITE DIAGRAM
BE,
DCHD (6.82)
7' 0-1