523 Boxwood Church Rd.
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Y� I
Au'rHORizA'riolv No: O$ � 3 DAVIE COUNTY HEALTH DEPARTMENT sW A
�� r,- ' Environmental Health Section PROPERTY INFORMATION
Permittee's ` ---�-� P.O. Box 848 O� ��
Name: ,,��,�,4�—�'J✓� _.rJOJy'�S Mocksville, NC 27028 Subdivision Name: '7-�S-�J7 '
�� ' � ^ �' / Phone #: 704-634-8760 ���
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Directions to property: .: ����',�.U�^G'�/ � �' �' " �
Section: Lot:
AUTHORIZATION FOR / �j
WASTEWATER Tax Office PIN:# r'�'� ��",U' -�� � d
SYSTEM CONSTRUCTION
Road Name:���CriDc�;-l_ %��1 • l�p;� `°� � {�v�s'�
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pemuts. "
'(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
, J � `� , � �,,'� � ***NOTICE**:x THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '
" j�r.�� y J.f��:=�=� �'`'i �` '' '%"i' IS VALID FOR A PERIOD OF FIVE YEARS. .
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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-0_� � S�`� � DAVIE , COUNTY HEALTH DEPARTMENT ,,� ��- l f
-' '-� �.��.�; .� " I M P R O V E M E N T A N D O P E R A T I O N P E R M I T S P R O P E R T Y I N F O R M A T I O N � j J,�; E!
Pernuttee's'� "� '� �
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Name �' ��" �l`��� ...-f.' r�y�?��
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Directions to,property: r�
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Subdivision Name: ''�-?y'-��
Section: Lot: " ��A
IlVIPROVEMENT �..� r-: ,.� !, : �, : ..1. ';,
PERNIIT Ta�c Office PIN:# : ' /' � "' : �.. �' - i � �
,
Road Name �� •� f �(f - r�� f 1
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**NOTE** This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATTON FOR WASTEWATER SYSTEM CONSTRUCT'ION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMTf IS SUBJECT TO REVOCATION IF SITE
s ,,; . , , ; ,� ,, , ' , j <;, -. PLANS OR Tf� INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �Q,1L,� # BEDROOMS �,_ # BATHS �� # OCCUPANTS _L GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY Tl'PE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE l TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) -� ��i �'} NEW SITE /,�/ REPAIIZ SITE
SYSTEM SPECIFICATIONS: TANK SIZE �GAL. PUMP TANK GAL. TRENCH WIDTH ,� l� ROCK DEPTH �� LINEAR FT. �
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMTf LAYOUT
�
**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:
� i�
. �� �� �
� ab� r
AUTHORIZATION NO. c/ v OPERATION PERMIT BY: � DATE: �I
� ,
**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 OS/96 (Revised)
' ,, APPLICATION FOR SITE EVALUATION/IMPROVEMENT
� � Davie County Health Department
w Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760
[�'I� ��A�I'�� ,r � � �'�i��..� �-,.�
,
;
��"'
��� APR 2 I 1997
� ' i .-
****IMPORTANT�*** THIS APPLICATION CANNOT BE PROCESSED UNLE5S ALL
THE REQUIRED INFORMATION IS PROVIDED.
� .
1. Name to be Billed ' � Contact Person E'� �- �
'� 9�
Mailing Address � Home Phone
City/State/Zip�J��'�SrI�T�� ���� ��l "'�,� Business Phone �d � 1-- l 0�-- (D L��s -
2. Name on PermibATC if Different than Above
Mailing Address
3. Application For: [] Site Evaluation
City/State/Zip
[ ] Improvement Permit & ATC [�oth
4. System to Serve: [] House [] Mobile Home [] Business [] Industry [] Other
5. If Residence: # People� # Bedrooms� # Bathrooms� [�Dishwasher [� Garbage Disposal
[/] Washing Machine [] Basement/f'lumbing [] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers� # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [�unty/City [] Well [ J Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes �].No
If yes, what type?
E I Tt1E1Z tL YLtIT OR S Z TE 1'L�IN
PROPERTY IN ORMATION REQUIRED: *** IMPORTANT *** �r".�`I:�ffiT�OF THE PROPERTY MUST BE
�ho�� r�C�d-�� �i�l�° j hom�L/�t,�21"'�� SUBMITTEDWITH SAPPLICATION.
Property Dimensions: -' aC-�-�- � r W� DIRECTIONS (from�cksville TO PROI
� �' -�
�� 'aac Office PIN: #� - � � - ��7 l �� � _._�`1��._,_/�2�/��� — /U�dJ '� �
Property Address: Road Name z�c�x- �0d� �Vl • t��- � �%r� � �l � tt>C�_!C� � k �
City/Zip � %�o� 0 � t
If in Subdivision provide information, as follows: �
�
Name: � � �
� _
Section: Lot #: ; U -5
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all chazges incurred from this application. 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 e E. �` e 1 la.. �
DATE � T � ��' � � SIG:
Revised DCHD (06-96)
to co�ct all
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to determine the site suitability.
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� • DAVIE COUNTY HEALTH DEPARTMENT
�• w
-� Environmental Health Section SECTION LOT
SoiUSite Evaluation
--.�-{--� /
APPLICANT'S NAME �l D/U�S DATE EVALUATED �< �% �
PROPOSED FACILITY �%%� PROPERTY SIZE �
SUBDIVISION ROAD NAME ��iYl�/'G� ��
Water Supply:
Evaluation By:
FACTORS
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
On-Site Well
Community
Auger Boring E� Pit
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
1
L
SITE CLASSIFICATION: �S
LONG-TERM ACCEPTANCE RATE: �
REMARKS:
DCHD (01-90)
�
�
2
0
Public v
Cut
3 4 5 6 7
EVALUATION BY:
OTHER(S) PRESENT:
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
Moist
VFR - Very friable
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
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
Mineralo�v
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 - gallday/ft2
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