284 Oakland Avenue Lot 117-118DAVIE COUNTY HEALTH DEPARTMENT
t IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**kTE** 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)
NAME .-T�1,4 A,0/0ROPERTY ADDRESSDATE
LOCATION��Ay,���
SUBDIVISION NAME �✓Jf /i9�i� 'i /7 / r LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE N BEDROOMS _�/ t BATHS # OCCUPANTS AL GARBAGE DISPOSAL: &No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEDFILE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE_TYPE WATER SUPPLY i�ZJ DESIGN WASTEWATER FLOW (GPD) _+i NEW SITE REPAIR 5ITE
SYSTEM SPECIFICATI(NS: TANK SIZE/ GAL. PUMP TANK GAL. TRENCH WIDTH �'�' ROCK DEPTH /-.i LIMEAR FT. �'D6
OTHER
REOIUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PIANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY Ile? �f
**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. y
OPERATION PERMIT
AUTHORIZATION NO. U 371 2
SYSTEM INSTALLED BY , �' R -►' R P Q f i
�A.
F
m. 6 ,r4,R
,p,
Iboj
/001
OPERATION PERMIT BY C\`S w C�- DATE I -106
**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
v�
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
4 ,* P.O. Box 665 .
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION!
(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.***
..�..,
DATE
7A�
AUTHORIZATION NUVBER
�'v_ 0 7 2
NAME ���'r
t _ L9
3
NAME ON IMPROVEMENT PER�MITT
(If different than above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*fmNOTICEfmm THIS AUTHORIZATION FDRST�WATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVI AL HEALTM SPECIALIST DATE
DCHD 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMITFILM
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By Ja pub Af I
Mailing Address S D na, 1A nnOI ( Z � S 1 �C �- Home Phone uO ' 1� Z �g2Si
Y T1 I'�GS L_L_ . C- - �� Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House "] Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Oi/W/0) Llr,444 5 Section Lot # 1?
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms Washing Machine
No. of Bathrooms Z b Dishwasher
Dwelling Dimensions X� NE Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: -S Public ❑ Private `_ El Community
8. Property Dimensions A-0 XIV u 930 � 191 Sewage Disposal Contractor U SKr OW13 Q{- TIJ S
—9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes '] No
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.
PROPERTY INFORMATION REQUIRED:
Directions to Property: NrA �y�
�.i nj on �tk(an6 ow&(Xuke.I l to
on"h+ pOq OhKDQLe D4wv, Lcc� rd
This is to certify that the information provided is correct to the
incurred from t is pplication.
DATE
Tax Office PIN: # 01Z d' I rJ 1
PROPERTY ADDRESS, as follows:
Road Name: OAKi J. Ak)enato
City:.
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
my knowledge, and I understand I am responsible for all charges
URE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: ❑ 1. 1 OWN the property. k1 2. 1 DO NOT OWN the property.
ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized represents iye of the Davie County Health epartment to enter upon above described
cated in Davie County and owned by , k)P. C�11 d _b0 (.gI M) T e ✓
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
al system.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name le/GK �%fT°✓D Date �-
Address 27 l �T ST2ec f Lot Size
/lvcr-xv, c c- /(4,-- Z.7a2 r
FArTORR ARFA 1 ARFA 9 ARFA R
ARFA A
1) Topography/ Landscape Position
S
S
P
S
PS
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
q
(D
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
&
S
S
Clayey Soils
PS
PS
U
U
U
U
i) Soil Depth (inches)
S
S
S
6)
PS
PS
U
U
U
U
i) Soil Drainage: InternalS
S
PS
S
PS
PS
U
U
U
U
External
S
S
S
PS
S
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S.
S
S
PS
PS
PS
PS
U
U
U
U
i) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally S le
Described bySj�
4 Title
SITE DIAGRAM
*67-WA1 - .S'7,-4 'r --E A erF;
DCHD (6-82)
491• Lr
• " APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 3 YK3 2-
1.
1. Permit Requested B "2/�_ S�� usiness Phone 9l) '1 - 0513
2. Address ' / � 107 S' v' csi`.C'(1 Af C 47-024
3. Property Owner if /Different than Above
Address UJJI n 14V&Z) C -
4. Permit To: a) Install_,L Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. ? Lot No.-& Yf
lf
5. System used to serve what type facility: House Mobile Home ✓ Business
IndustryOther
b) Number of people—3
6. a) If house or mobile home, stale size 9f home mber of rooms.
House Dimensions (9 S
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 =2 urinals garbage disposal
lavatory 3 showers 12 washing machine
dishwasher y 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
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
;7S
to ce ify that the information is correct to the best of my knowledge.
/
DaiW Owner ignature-"
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ie -ti 6�
Y
'�j (1..,! G' � ,
�J �--'--�"^' !�
�1t✓ity,�.l�,(i �C-�tl� S
�J�IT / AJ G�-�
Cl '? 9'.-
DCHD (6-82)
D
rn A -71? -164A)
DAVIE COUNTY HEALTH DEPART.^4ENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2.t . r -emit t-he—amount—due .,ment.
3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
GGs'
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARLVIENT,P.O. BOX 75"
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY:
DATE RECEIVED
(office use only)
yes no (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above d�ej� cribed property, however, I
certify that I have consent from Vf kfih./) 9, k6oZU ,owner to
`✓'�� �. owner's name
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) I hereby give consent to the authorized representative of the
Davie County Health Department to enter upon the above described
L_fl L..__: property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
q 11,2413
TE
SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
40 J60
DAT
SIGNATURE n
Owner Only
Owner's designated representative
Anyone requesting results
Only tthose listed below