118 Fancy Button LnPermittee's_ DAVIE COUNTY HEALTH DEPARTMENT fat
Name: 7f7 ra r; m (ti's !{ �j r ` Environmental Health Section PROPERTY INFORMATION
4:. 1
- P.O. Box 848
Directions to property: Mocksville NC 27028 Subdivision Name:
Phone #: 336-751-8760
( -(
Section:_
1 AUTHORIZATION FOR
R' A STEWATFR
Lot:
SYSTEM CONSTRUCTION Tax Office PIN:# - -
AUTHORIZATION NO: 0027999 A Road Name: �' `' ` `1 = ' ` ' l ` ' + ' p:
�Zi
. ,
**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 Forn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
71,_ .' . ; �t''✓°r" �_:%l•'t �% " a�J �U IS VALID FOR A PERIOD OF FIVE YEARS.
NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 14 # BEDROOMS 3 # BATHS # OCCUPANTS 7) GARBAGE DISPOSAL: Yes or.Nq
COMMERCIAL SPECIFICATION: FACILITY TYPE
# PEOPLE # PEOPLE/SHIFT
# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE G r f TYPE WATER SUPPLY
DESIGN WASTEWATER FLOW (GPD)
NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE °� ' GAL.
`PUMP TANK N GAL. TRENCH WIDTH
L " ROCK DEPTH t 1 t
LINEAR FT. -�U C' +
tV+iJud� -t Pipc cT 3Ce1 Ltn
5 r` Fc•' 0r}i. l��x,
cfG .
OTHER�T. 1 I
.ri �� �` <'I. �Jo�=-)4V
/ .. ��, �s . r^Jr- u.
n��r, J( Sc✓. 1,1
ivclur
/
Gvcl l�� �..> J
REQUIRED SITE MODIFICATIONS/CONDITIOI�IS:
IMPROVEMENT PERMIT LAYOUT
11 FOR FINAL INSPECTION OF THIS SYSTEM PLEAS GOIL Bgl'WEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT V.), i C—
!�a L Qt -t
kt "4
AUTHORIZATION NO) OPERATIO PERMIT
BY: b `t CY (l
�Q'7
c
�I s
7
DATE:
UC,lU-P_
**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
/W,.IILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02102 (Revised) Jf'( �'� :12
,
Permittee's DAVIE COUNTY HEALTH DEPARTMENT n}
Environmental Health Section PROPERTY INFORMATION 9 C
P.O. Box 848
Directions to property: Iv1ocksville NC 27028 Subdivision Name: 1
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 0027
a 9
A Road Name. 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 compliance with Article 11 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 f'( # BEDROOMS # BATHS <I # OCCUPANTS 7) GARBAGE DISPOSAL: Yes orN4
i
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
•> 1
1
LOT SIZE ` �' ` r -d TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE I " GAL. PUMP TANK _ „r/' GAL. TRENCH WIDTH ROCK DEPTH t t 1 1 LINEAR FT. •--' j C- r
Q��1�j�.J� !:;'.., s l .i �>.�,e {: ( 7-��t.� (,.. � .. t r �•,i. �.C+ , . �G .
OTHER_ nx�i ! 1 ;� rt 1. tarty•, t c. '/� ( r., i' rf: rry41
REQUIRED SITE MODIFICATIONS/CONDITI fig: i I, n
ti
IMPROVEMENT PERMIT LAYOUT --=` ,h,
f�
a a
07
FOR FINAL INSPECTION OF THIS SYSTEM PLEAS CA BES EEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
L
OPERATION PERMIT
vie 14f
SYSTE� S LLED BY: % Y
y nl (-C,) Sc.IA,
� 13
AUTHORIZATION NO.,j 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.
DCHD 02J02 (Revised) f{ �i i00
1
t
APPLICANT INFORMATION
Water Supply: On -Site Well
Evaluation By: Auger Boring
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
Community
Pit
PROPERTY INFORMATION
Al--1Q—D
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L L—
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
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE d.
SITE CLASSIFICATION: M✓.: w.' , 4k
LONG-TERM ACCEPTANCE RATE: Z. 2-73'
REMARKS:
EVALUATION BY: —21
OTHER(S) PRESENT: 7.•✓v! ..a11
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
MQ1St
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
mil
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)
NAME l u n'1 1 G/
M4
ADDRESS 0 l
DIRECTIONS TO SITE
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) qqk-d
(� (�
be PH NE NUMBER-&A�
& AOMSiOBDIVISION NAME
Y-�0 e
LOT #
DATE SYSTEM INSTALLED �1� NAME SYSTEM INSTALLED UNDER C evL '
TYPE FACILITY i%(S� NUMBER BEDROOMS NUMBER PEOPLE SERVE
TYPE WATER SUPPLY &k{'/ SP CIFY PROBLEM ICCURRI G Tq/t/lz /N
7W k / k1 9 h 60, W -A r 1A mj)
DATE REQUESTED O INFORMATION TAKEN BY"
(94,16q
is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
OW
a'
MIN
P
i
4
v y
v
s
�u
e+
s ,
�e
i
I
P
a
r
,