148 Barnes Rd ` Lj
Permitt;.es t �DAVIE COUNTY HEALTH DEPARTMENT
-'Name: y,`�. j�� �/�1 _Environmental Health Section PROPERTY INFORMATION �iJ j
f 6 �� � (J J O�' i�� P.O. Box 848
D' ctions to pro rty: Mocksville,NC 27028 Subdivision Name:
Phone#:336-751-8760
Section: Lot:
a AUTHORIZATION FOR
�� Cta ►� tp / WASTEWATER Tax ffice PIN:#����- �G
SYSTEM CONSTRUCTION 9� � n
AUTHORIZATION NO: 003021 A Road/Name: °r lf' Zip
**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 complian with Article11 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.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
�
RESIDENTIAL SPECIFICATION:BUILDING TYPE r#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE.` ` #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
IAT SIZE /`� TYPE WATER SUPPLY r ` `r DESIGN WASTEWATER FLOW(GPD) U NEW SITE REPAIR SITE r
tA C7
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH I EARFT.
OTHER
0� cl� Cl�C IfGH
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
1 �\
pwM N Car
i A
1 Bid Df
i
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-9760.
OPERATION PERMIT
SYSTEM INSTALLED BY: 4 �� �5 J ��'v i v► G,
got
AUTHORIZATION NO. G- o OPERATION PERMIT BY: DATE:
**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.
Dean ozrot(Revises) -SY7/ . €;. _ -1/l u•
F.- DAVIE COUNTY HEALTH DEPARTMENT 1
f o ? �' Environmental Health Sectio jty a, PROPERTY INFORMATION
Narnei I v
a P.O. Box 848
•►*r Directions to property: ` �� ��' t' Mocksville,NC 27028 . Subdivision Name:
Phone#:tr� 336-751-8760 Section: Lot:
AUTHORIZATION FOR
) l,/ � If Gf tr x rc� rN
WASTEWATER Tax , G l
SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 003021 A Road Name: Zip: a
**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 comp)iance with Article 11 f G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
iw
4 / /*�**NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
��f e IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE IISSStJUE�Dn
RESIDENTIAL SPECIFICATION:BUILDING TYPE ✓_ /#BEDROOMS 3 #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 w DESIGN WASTEWATER FLOW(GPD) U NEW SITE REPAIR SITE
fr
SYSTEM SPECIFICATIONS: TANK SIZE 2AL. PUMP TANK' GAL. TRENCH WIDTH� ROCK DEPTH IN�EAR FT. 260
j
clt"l �{J1CydU
OTHER ��rtri
7
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
eXrS`I,✓' y
DW/"\ H Car-
0-1
i /
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: rN .r j'r/" trt r
Ok
I CC
) \ r
_ I ,
Di
AUTHORIZATION NO.( OPERATION PERMIT BY: DATE:
**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. ,.
DeHD 02102(Revised)
•,� DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
1
�g
_7377 Zo
Water Supply: On-Site Well �-Community Public
Evaluation By: Auger Boring Pit Cut sev�
FACTORS 1 2 3 4 5 6 7
Landscape position
Slo % /
HORIZON I DEPTH
Texture group
Consistence k05 -Ply-
Structure
;rStructure
Mineralogy
HORIZON H DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE ? ,/
SITE CLASSIFICATION: �� EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: i Z. 7 OTHER(S)PRESENT: C
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear 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
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
33'et
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
Mineralogy
1:1,2:1,Mixed
lYQtes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-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-gal/day/ft2 DCHD 05105(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME t f 1 PHONE NUMBER
ADDRESS ( `` ce d rA !S SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY �/� NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY we'G( SPECIFY PROBLEM OCCURRING IQ L I in
DATE REQUESTED �tJ INFORMATION TAKEN BY eoia /V �C-1 to
This is to certify that the information provided is correct to the best of my knowledge,and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1193