2034 Angell Rd �
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Section: Lot:
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SYSTF.M CONSTRUCTION Tax Office PIN:# - -
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AUTHORIZATION NO: A Road Name: - �' � ` Zip. �
**NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Permit�.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pennits.
(ln compliance with Article 1] of G.S.Ch�tpier I30A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
,,�, `.. ' ; / / ,-. ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
.••--`�''�t ; �' � :' �,•' w.-..—., _,,,.-'�{�—�/�'—'� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONIVIEN�AL_HEALTH SPECIALIST.._ ' DA E IS� SL�ED
RESIDENTIAL SPECIFICATION:BUILDING TYPE� �-� � #BEDROOMS�^_#BATHS �f_ #OCCUPANTS E GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
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IMPROVEMENT PERMIT,L;4YOUT \,
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*"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY M DESCRIBED ABOVE HAS BEEN INSTALLED I COMPLIANCE
WTI'H ARTICLE 11 OF G.S.CHAP'fER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTTON SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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. . Directions:.to_pcoperty:� '` } #'�" � 1�1ocksville,NC 27028 Subdivision Name:
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Section: Lot:
AUTHORI7.ATION FOR
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AUTHORIZATION NO: A Road Name: �'�t� "- •'` `"`Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Permits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections
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(ln compli�nce with Article 11 of G.S.Chapi�r.130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ..__ •-
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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.
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. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ���-�Z��I h..�b�-L PHONE NUMBER `�� Z���
ADDRESS /iC/�'I �NV�JLIi �� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
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DATE SYSTEM INSTALLEp NAME SYSTEM INSTALLED UNDER �J�^-V�
TYPE FACILITY DI/�I� � NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ����� SPECIFY PROBLEM OCCURRING ��.�.�C1�J�
DATE REQUESTED � � d INFORMATION TAKEN BY
Thi�is to c�rtify that the information provided is eorceet to the best of my knowledge,and that I understand I am r�sponsible for alI charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
R.,�.,roa
� • ' � DAVIE COUNTY HEALTH DEPARTMENT
• ' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INEORMATION
f--1��+�E� 2A� .1�C�0.E--�
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Water Supply: On-Site Well Community Public ✓
Evaluation By: Auger Boring Pit Cut
FACfORS 1 2 3 4 5 6 7
Landsca e sition
Slope% 2
HORIZON I DEPTH D�
Texture rou C L
Consistence
Structure
Mineralo
HORIZON II DEPTH (o - �
Texture rou G
Consistence
Structure P
Mineralo �
HORIZON III DEPTH 20 -
Texture rou
Consistence �;
Structure
Mineralo
HORIZON IV DEPTH - Pj
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS �–
RESTRICTIVE HORIZON ^
SAPROLITE "'
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY: c--�'�—�c�%`�i�
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
i.�ndscape Position
R-Ridge S -Shoulder L-Lineaz slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S-Sand LS -Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
.ONSIST .NC .
1l�ist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
NS-Non sticky SS -Slightly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
�S
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saproli[e-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2 DCHD OS/OS (Revised)
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? '� +� �" � DAVIE COUNTY HEALTH DEPARTMENT � �; ,�� �� �
� . _ . . IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ; � `
�
"�IQ�E: 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�,�5{�" �„ k-. �L�C�`.�c�;=_� Date -� � `'>U ' ����1 N� ,,�j`���'}�:,
Location ��'� r<� �� �,� `���j ��o���;v�\�: o ``J .�:.. �`��.10 ��( _ .
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c�1 1'v -- _ _ .�{� -L-- - ` � � �
l�'�\ �'`c�. �',.�v ..`�i�. ��\� I D ^r�,�_.Q �7'\ \=�•�'��� \�-��-s_J� �':.;)�.�2r�
' � �
Subdivision Name Lot No. Sec. or Block No.
Lot Size ` �'-����- House Mobile Home _ � Business __ Speculation
No. Bedrooms --: No. Baths �- No. in Family r~ _
i Garbage Disposal YES p NO [� Specifications for System:
a'�; Auto Dish Washer� - YES ❑ NO � J U o:� -, .�� ,.�-,��� - �._ ' ��`',�
Auto Wash Machine YES � NO �p ` .. �y 1;
���� r�, r�,�� � , � ^,
�t TYPe Water Supply � Q ` �cL_ _ `-. � �: .:� % � n,
� J+_� _
1 , `
*This permit Void if sewage system described below is not installed within 36 months from date of issue. �
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Improvements permit by � ��- _=,�' `'
*Contact a representative of the Davie C unty ealth Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M, on day of ompl tion. Telephone Number: 704-634-5985.
t_,...�:,, �: � . �-�_ �� s...�r_...�
Final Installation Diagram: System Installed by ��,-=�- ' ���-
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Certificate of Completion \ ! �'�'� Date � i��� c� �
"The signing of this certificate shatl 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.
ti
� � v APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section �ECEIVED.MAY 2 # �
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
� c�a�-� �. l�at►�i���'�-�� Home Phone �8"��C98
1. Permit Reques��B�1; Ai'I'lP�S � _ �(i r+�bre�I Business Phone
2. Address � OX ,(�� �Q(��Sui�l E � C . �7�g
3. Property Owner if Different than Above � ��-��,s r � '`,i v�9��1`'�-��
Address �� � �a7c 1 3 �{ j'V�.�ss���.`-.�i�,1•� N•C.
4. Permit To: a) Install�Alter Repair
b) Privy Conventional��Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home B�s
Industry Other
b) Number of people �
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions ��� �
Bed Rooms � Bath Rooms �L Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, eta
Estimate amount of waste.daily (24 hours)
7. Number and type of water-using fixtures:
commodes c�,, urinals garbage disposal
lavatory 3 showers � washing machine �
dishwasher sinks
S. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes ✓No
9. a) Property Dimensions i �S..b.Q
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 rype?
This is to certity that the information is r ct to e�es � dge.
� � l � ' � ` `
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: � `�L
�a � l�J � � � � � ��`'�'" ° T
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t �(/`.���.J l.�`�/`'C. � �"� �� � �� .
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DCHD(6-82)
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+ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Hea:th Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � ��..� Q. �� ��'��� "R e,\\ Date b� � 3 � - ��
Address � � m� Lot Size 1 C�`S"
FACTOR$ ARE 1 ARE 2 AR 3 . AR
1) Topography/Landscape Position S �--- S
�P�, �P� PS
`� �
2) Soil Texture (12-36 in.) Sandy, S �
Loamy, Clayey, (note 2:1 Clay) _��PS� PS
� � U U
3) Soil Structure (12-36 in.) S S �
Clayey Soils � � �R
U U U U
4) Soil Depth (inches) , � �,
PS PS PS PS
� U U U U
5) Soil Drainage: Internal . � �_ S ,�\
PS � �R�.�
U U U
� External � � � `j\
P `i?�
� U U U U
6) Restrictive Horizons �-- -� --��
��
7) Available Space S
,P , �-P � S
<� `rj_' U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification ,� S � �
U—UNSUITABLE S—SUITABLE PS—Provisionaliy Suitable
Recommendations/Comments: �� � 5 a �� - � �� � �� �� ��.,1�
�1'1J� Uy �O� •tCr T..,. O 1
Described by �, Title ����-��`�-��-h�- Date�'S'"�o `"�
SITE DIAGRAM
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UCHD(6-82)
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_ .__._.._.._ _,
, i-' - , D IE COU TY HEA -#�f=D aR'MENT
=�=:.,.
` ' 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 �!'��m c ��C�r����:,�s c c_ — Date t�� ' �; �-�c! ' �:',�,;a-:
� . .. . a1 v ,.:,
, ; � � , . _
Location !�c�/ /Vn,z. T✓/ �'� . ��._, �1-r�ca •r �. �� �� C,;. � r�;� ,� ; or� C.> r ;— .�s< < <��<<,
!,�i='�� k� t�/:��.�f_
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 ❑ NO ❑ Specifications for System: �Do:�������� �``` �-
Auto Dish Washer YES ❑ NO � � � •�
Auto Wash Machine YES ❑ NO � �av '� ` -'� �2 ��ll��f
Type Water SuPP�Y — -�o v� --- 1, " .��x ��._� �<,,.�<<<•�� %�
'This permit Void if sewage system described below is not instal�ed within 36 months from date of issue.
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Improvements permit by =��''�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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by �-, f�-"•�%� `� � � '�'� ' P '{�'
_ � ! ,f
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�„�.- ;i�� � r .��/ � �.L�
Certificate of Completion __.�.����'���! Date � . '��'`��' .��
,
AThe 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 sqstem will function
satisfactorily for any given period of time.
� f .:� ' �
� DAVIE COUNTY HEALTH DEPARTMENT �
Environmental Health Section
P. O. Box 665
Mocksvi{le, N.C. 27028
SOIL/SITE EVALUATION
Name ��"� K«��� Date ���- �T
Address f`T � i3`X �3� Lot Size
%yl,f7C�1'1i/cL t �G
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position � S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S � S S
Loamy, Clayey, (note 2:1 Clay) � ���Ps) PS PS
� -Ct' U U
3) Soil Structure (12-36 in.) S� C� S S
Clayey Soils PS PS
� U U U
4) Soil Depth (inches) � S S
PS S PS PS
� U U U
5) Soil Drainage: Internal � S S S
�PS� PS PS
� �� U U
External S � S S
� PS PS
U U U
6) Restrictive Horizons
7) Available Space � � S S
pg PS PS
� U U U
8) Other (Specify) S S S S
pg PS PS PS
� U U U
9) Site Classification f�.s P S
U—UNSUITABLE S—SUITABLE PS—Provisionaliy Suitable
Recom mendations/Com ments:
Described by �� '� Title �''�`� Date�1` � �—
SITE DIAGRAM
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OCHD(6-82)
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�, ,,,,.1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
�2.t. a�' 1 Davie County Health Department
-rdf,�, � W�'�' Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
, Home Phone � �
1. Permit Requested By.���Y`�'�'iNe-�� ��s Business Phone 'Ss ' � 3��
2. Address ` � 3 r
3. Property Owner if Different than Above � r �� � � ��-' �
Address� � ��� S y
4. Permit To: a) Install�Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home �s
I Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �v �� � �
Bed Rooms�Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Nu ber of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes � urinals garbage disposal
lavatory �- showers washing machine �
dishwasher / sinks .�
8. a) Type water supply: Public Private Community ���
b) Has the water supply system been approved? Yes1' 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? ,�jO
What type?
This is to certify that the information is correct to the best of my knowl dge.
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� Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: (-�e�Z��/2J�
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DCHD(6-82)
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