509 Beauchamp Rd..,,., _ � - .,.:�,� ,� :- :.;a, .- :; . r , . . . ,.
.' . .. � '# r _ ,� .A � O J,
AUTHc�Ri�ATiorr No: `� ��� DAVIE CQUNTY HEALTH DEPARTMENT .
- • Environmental Health Section PROPERTY INFORMATION
Permittee's PA. Box 848
Name: '�q���`��?���-" ���'�•��'`�-� Mocksville, NC 27028 Subdivision Name:
Directions to property: �```��.� "�C.: �,C.>� .�j, Phone # 336-751-8760 Section:� Lot:
� f , � AUTHORIZATION FOR �..
il ?�,. ~ WASTEWATER '�] �, ,�� E�,/"�',
� r�� t y�� ���"� �`a' �n SYSTF,M CONSTRUCTION Tax Office PW:# ��+ �`� �3� "�`''
� =t� r"��.?'�1�.!!1 D.,3'�c.� �1 l�':1t1��1w �rt �IL Road Name �1������f �� • . �rFl r7 a
i�il ``,_�c.�i� C, ►L:,.J . �t' �Z�p. �- �' ^�>, �`
**NOTE** This Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Sectionprior
to issuance of any Building Permits. This Form/Authorization Numbershould be presented to the Davie County Building Inspections
Office when applying for Building Permits.
, (ln compliance with Article I 1 of G.S. Chapter 130A, Wastewatec.Systems; Section .1900 Sewage Treatmen(and Disposal Systems)
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% i�,:'-' ,� �.� �•y ***NOTICE*** TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� �; �..�'� f��°�.; ,�--, ' Z Cl IS VALID FOR A PERIOD OF FIVE YEARS. :
ENVIRbN 3� y 1 E N T`�4THEALTH SAECI� ST� DA E IS UED
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. __ . 11 � J
" � ,�; '� '� % � � DAVIE C UNTY HEALTH DEPARTMENT '� � °
x: "''== � � TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
,,
- Permittee ; ` , '
N�m���_ f ��y1`�^�d� "� �"`��'�*�-�+�. � Subdivision Name:
� S, �,;
Directions to property: �'� w �' �-- ��`` � Section: Lot:
�- � , IlVIPROVEMENT t�� %� y-, t-.-�-, j/r��y
r' � �E �,C• ,j ....� � !;•✓
`., ,� �:: r--i �... ` � 3 f �< � � _..i� �' ; ., PERMIT Tax Office PIN:# `� �a � �� - ""'
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.�_ , ,,
.; f;y
4!�... .�" . t ..- \ 1' C' t 1� r. �..� Y� y! i. i,� ��. i� f - �' y ••` n .rs i� �r,F'i, �,�,. r�,n; I+.. .
..y..t �� � �f � � �' t "'s� .�� _ �e`i t. � �c:� x � . �- Road Nam���aa�A�,:�'.,.�b''�i�:T����Zip: � � ��.'''�a�_.
**NOTE** This Improvement Permit DOES NOT authorize the const�uction or installation of a septic tanlc system or any wastewater system. An �
AUTHORiZATION FOR WASTEWAI'ER SYSTEM CONSTRUCTION must be obtained fi-om this Department prior to the
construction/installation of a system or the issuance of a building pemut.
(In compliance with Article 11 of G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
w-% "�••, ***NOTICE*** THIS PERNIIT LS SUBJECT TO REVOCATION IF SITE
;" ;�,.., � f� °,� <=- •"y ��`" PLANS OR Ti� Il�TENDED USE CHANGE. YOUR WASTEWATER
�� ' ENVIRONMENTAL HEALTH SPECIALIST DA I SUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
; , INSTALLING TI� SYSTEM.
�. •
RESIDENTIAL SPECIFICATION: BUILDING TYPE � ti"� # BEllROOMS Z# BATHS G # OCCUPANTS � GARBAGE DISPOSAL: Yes oc�i 'o�`
COMMERCIAL SPECIF[CATION: FACILTTY 1'YPE # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
�%,2A,�Q�'S� -�.,/ /
LOT SIZE✓• J TYPE WATER SUPPLY�N 1� DESIGN WASTEWATER FLOW (GPD) Z�C.� NEW SITE ✓ REPAIR SITE
�� '.� .^7
SYSTEM SPECIFICATIONS: TANK SIZE .� L:o�GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH � LINEAR FT. G�,
OTHER � .y`"1��Tk=-� ��I i C7 ,I� f�XC",��
� !
REQUIREDSITEMODIFICATIONS/CONDITIONS: If�ZU�,�.. C►�i CGr.J7Ut/� ,�_::_t_.i'� � o�� �fl. (-�l�M %
_ n
PERMIT LAYOUT s�pp(�����
I�' G*� L��i.�T� F'Ii�ISi.ED G�A � J�(
�� {z-`'�
���� �� ��
"*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 - 130 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
I OPERATION PERMIT
�-,�a,�
A�-�
SYSTEM INSTALLED BY: ��� � "" 4 ITI���
M,� ��-�t�v.,._.�
, � �...� .
° . � 70'
..
�An� 1� 'DAT� ja-23
i°"�'��
�
�`�,�s;
g�� x�"x►y" i�'-rs'
�
AUTHORIZATION NO. ���� OPERATION PERMIT BY: DATE: �
�'��TEIE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT T S TEM DESCRIBED A VE HAS BEEN INSTALLED N COMPLIANCE
WTTH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPUSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
/ APPLICA710N F011 SITE EVAWAiION/IMPROVEMENT PEAIHIT dc ATC
n��/ �r , Davie County He�lth Depanrnent �
��'"�►rr`� � - Envi�nmenla/KealtfiSe�cdon
� P.O. Box 8�8/210 Hoapital Streat �
Mockaville, NC 27026
�336)751-8760
l�l
F� I 21999
I •**,TltPO�TANT*** THI3 APPLIGATION CANNOT 8E PROGTESSED UNLE33 ALL TNE REQOZRED
INF.'ORMATION I3 PROVIDED. Refer to the INFORMATION BOLLETIN for instructions.
=. a�� cp � Hsiiea �►�1 iC�Nfl�L �./Yl0 � K contzot n�� f.3 i I 1/� ac.1G
Nax1 inq Address .50 ��EAG�C /-/�q /r►P P� eoma �one Q�1 Q� - 5 6 0 2
City��8tate/LiD I7Q✓I�►�C� ��C. � i00�o Business Phone %2%' S3�'�,
Z. liame on Pe=fniL/!1?C i! Di!lerent than Above �
llal'I.in� 1►ddress City/State/Lip
3. Ai;;,:!!.�.c%1�::oII SOI: L S�te EVa1118�.oA U Ia�roveio�ent Pesmit/ATC ��iqth
;. sysr�,-.m to service: CJ Honse �Mobile Home � Bnsineas U Iadustry ❑ Other
s. If R�esidenae: � People Z i Bedroo�s Z ; Bathrooma �
0 Distnrasher 0 Oarbaq�e Disposal �;Nashinq Hachina 0 Sas�ment/DinmbinQ 0 Sasement/No IIivai�ing
6. I! Bnsiness/InQustiy/OEhes: Specify type � people f Sit�s
� Commodea / 8hawera � Urinals i ilater Coolera
IP -FOa�SERVICB: � 3eats Estimated iPater Uaaqe �Qaiions per my)
7. �.`ypa �.f.' r►ater sv�.lp: � Connty/City 0 i%11 0 Cams�nit�
e. Do yo� anticipatr. �a�ddi8��ns or eapwnsions ot the facility this tyatem is intended to aervef ❑ Yes �No
:�i yes, �vbati �; oe'
*'"/M�'�'RTATJT'•" CLIENT� JIlUST CO�1lPLETE THE REQUIRED PROPERTY llVFORMATION REQUESTED
BELOVI'. .���tLer � FLAT or S1TE PL.AN MUST BESUBbtITTED 6y We dlcnt wlth THiS AI'P1dCATlON.
Property Dimenaions: �s� �/n�P WRITR Dltt�+-CtIONS (from Mocksville) to PROPLRTY:
,�-�fo Efls T rv 8a �
'ra:�tiice�PiN: #SS%0-6S3-SZ�-O Roi sa�TH To yiccSDAcERD, rPASTTA�C'HE6LBANANiI�
Go,
Prnperty Addreas: Itoad Namu �EA�e NqmP Ro .
Cicy/Zip AD✓ANCE� ^l,C. z7oa6
if in a Subdivisian provide information, as follows:
Name:
Section: Block: Lot:
R/bN7 a�+1 N/[tSoA« Td /�ot,e5 L'flv2�/� R�
R lG /f T o�✓ /YlOCKS CHd�CH �PD ,
n"lo�KS CN��GH �Po� To B�AUCH�M�Ro.
'C��ss R�,�vL'N�li»� ��� Tv /�R���1TE DRIf�
/�! FRoivT oF /y)oCKS Cr/v2`�-[� `�LLOGc�
/{I✓AT� �'p, ?o P,QvP��2T`/
Date Property Flagged: 2 /8�9�
This i� to certify t6at the ioformation pravided is ccrr�ect to the best of my knonledga I understand thst any permit(a)
issued l,e�eafter are subject to au�pension or �+evocatioo,lf t6e aite pl�ns or iateaded uae cbaage, or i� t6e information
�ubmitted in t6is �pplicatioa is talsitied or ch�nged I, also, uada�ta�rd tJbat I anr ryporisiblejor a// cba,ga incurred from
�3s applicatso,r. I, heneby, give conaent to the Aat6orized Representative o� t6e Davie County Be�it6 Department
tu eoter upoa above described property locuted in DAvie County and owned b�• DOR/S /rIoG,E!
to conduct ail tating pc�ocedura as necesssry to determine t6e �ite anitabilit�.
�,/� �%/ �/J
DATC ?�/3r`1 �l SIGNATURE __�c�("��rrt � i�'!�/�
THCS AREA MAY BE USED FOR DRAWING YOUR SI'�'L PLAN (include all o ot6e follo�ring: E�IaHng and proposed
property lina aad dimen:iona, atructutYa, setbulcs, and septic lo�atlons). �_ 700 � p �5 e
` -� N _ __ _ - - j �,LL�pL�/�
Q �' � �''� SGPTrG S�sf��
�' 1 �T � � �i--�4�,
o �-
0
0
�
�
�
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� :v�'.evlaed DCHD ((
� � .
--__
�
_EAUCI�fAMD r�: — --�
DR��
�—o
0
r P�ppasEp `o�
LD�R7�Odl�G� fJ�ML'
Account Na
lnvoice Na T / �
�{/o T�; AL L�D ul �,e� u/f} T6��
f�TEc�PN�n/� Foccaw s
ORI.✓E�tJA1/
. �
,�, � , .
APPLICANT'S NAME _
PROPOSED FACILITY
SUBDIVISION
Water Supply:
Evaluation By:
FACTORS
Slope % '
HORIZON I DEPTH
Texture Qrouv
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
SoiUSite Evaluation
�___----�
� � G�A�=�- ��< ��!`DATE E�ALUATED �r 3I) I�
� 4-IO �� PROPERTY SIZE � 3 �t�%r'-u>
ROAD NAME 1 i�i �it,Il�.t,yP �/
On-Site Well Community,
Auger Boring Pit
structure
Mineralogy �
HORIZON II DEPTH ;
Texture group . �
Consistence
Structure
Mineralogy -
HORIZON III DEPTH
Texture group
Consistence
Structure
HORIZON IV DEPTH
Consistence .
RESTRICTNE HORIZON
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SIT'E CLASSIFICATION:
1 2
� �
i� U
--r� � -�
iL C L
'" r5;
� S
i•` i
�- 7�%i in� L
Q ��
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-90)
Public '"
Cut
3 4 5 6 7
0
EVALUATION BY:
OTHER(S) PRESENT: � Lt— � �`'G�.
LEGEND �
Landscaae 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
Wet
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
Notes
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 - gaUday/ft2
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