2638 Farmington Rdom
Perniitte„ DAVIE COUNTY HEALTH DEPARTMENT
Name: V (�� l >e((1��5 Environmental Health Section PROPERTY INFORMATION \
` P.O. Box 848
Directions to property: F l Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
W t -t't" Ed 13.� Section: Lot:
AUTHORIZATION FOR
2L Q—, 2WASTEWATER Tax Office PIN:#
-
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002991 A Roam efm'r/Iq�oN ltd Zip: Z7�Z�
**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 FornVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen -nits.
(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 HENILTH SPECIALIST DATE ISSUED
• pennitt j i DAVIE COUNTY HEALTH DEPARTMENT
Name:Zra\ Ail(u, i fli�'t-� Environmental Health Section
r / P.O. Box 848
PROPERTY INFORMATION
Directions to property: Y rhATr 0 N 1cf, Mocksville, NC 27028 Subdivision Name:
f I ,� Phone #: 336-751-8760
1-, _so"1�141.rt� ter' Of, Section: Lot:
,�,'` I AUTHORIZATION FOR
t -I L� WASTEWATER Tax Office PIN:# - -
111""^" SYSTEM CONSTRUCTION
,•fie �` r f
AUTHORIZATION NO: 002 A Rod f1�7ame�_r1(t'11! il'"-(0�1/ (�t'1 Zip: G%1
**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 HEA TH SPECIALIST DATE 1 SUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE DISC # BEDROOMS L # 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 ad/f_ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE -/
SYSTEM SPECIFICATIONS: TANK SIZE GAL.PUMPTANK GAL. TRENCH WIDTH S ROCK DEPTH LINEAR FT.
OTHER
SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT N z
d 6k Ci �Q, Is S �t l� luC�rjLrin�� 7 /rl ('5141 Ziev-0-
O/L12 a
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:
1 SOS-\, l
AUTHORIZATION NO. OPERATION PERMIT BY: ' 1 DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESG IBED 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 02/02 (Revised) —0 6q
--7if -7 /,34
• Permittees DAVIE COUNTY HEALTH DEPARTMENT
Name: 1116-['rrt °its Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: -'t%r r'}°+ t7 �t.� �'<� Mocksville, NC 27028 Subdivision Name:
1 Phone #: 336-751-8760
1,117 L—
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 0 0 z" 9 �" I A
Section:
Lot:
Tax Office PIN:# - -
Rol lame! 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 FornVAuthorization 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)
''jj ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
it,41 - id ? i l i IS VALfD FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEA TH SPECIALIST DATE 1 SUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE /J�(f # BEDROOMS 5 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE'.LF�i` TYPE WATER SUPPLY 21A[It DESIGN WASTEWATER FLOW (GPD) .t� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER /S0 e xr /L -'i' t.- 111
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT x ,r
Glt� G lS S �(1 ll C'�i�Iln�S� /r��v 6�C/ 6,- C ��� S�iy� 'l
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 f -
,✓ SYSTEM INSTALLED BY;
10S E
AUTHORIZATION NO. 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.
I)CriD 02N2 (Revised) .; 03 _ _ � 1' - q,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Or(,. Mole �+�S
063k
J
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit
PROPERTY INFORMATION
Public r/
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Slope %
2
HORIZON I DEPTH
_y
Texture group
L
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
C_
Consistence
Pr
Structure
t(
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: e__s-
LONG-TERM
ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: W
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
CONSISTENCE
Mois
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
Mineralogy
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 - gal/day/ft2 DCHD 05105 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME 0(-aM/,-4L [')Md (V,S PHONE NUMBER ` qq-<- (b Ll I
ADDRESS 3 SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
Porux .
DATE SYSTEM INSTALLED Iq 59 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS_ _ _) NUMBER PEOPLE SERVED
C�l�tvi - h04"k
TYPE WATER SUPPLY Daf ut4,ecl SPECIFY PROBLEM OCCURRING SI6W
DATE REQUESTED_ l Y 1-7— (A INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all cWges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev, t/93 \ ow) I
CSF
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