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1731 Fork Bixby RdPermi ;tide's"DAVIE COUNTY HEALTH DEPARTMENT Name: � �%s 01"--�Zev Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property:/✓ f```' `' Mocksville, NC 27028 Subdivision Name: i Phone #: 336-751-8760 Section: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# 1 SYSTEM CONSTRUCTION i 731 Foak-8-i AUTHORIZATION NO: 002618 A Road Name: Lot: . Zip: zlv **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) 1 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS 2_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)'. -5�0' NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH -S ROCK DEPTHLINEAR FT:- OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: q� v_ C� Q 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. N OPERATION PERMIT t ©t I SYSTEM INSTALLED BY: VA ',e- 6 �� �!'� v �I n \ Acv e UTHORIZATION 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. DCHD 02/02 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Name =„��5 l _l�/'i? �% Environmental Health Section PROPERTY INFORMATIdN P.O. Box 848 Directions to propetiy: r' F' '� Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 - — AUTHORIZATION FOR Section: Lot: t ,t WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION 1731 !OlZ�t- %a'bc�10 AUTHORIZATION NO: 002618 A Road Name: Zip: Z�dl1 **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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 # BEDROOMS # 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 % / DESIGN WASTEWATER FLOW (GPD), ' (/' NEW SITE REPAIR SITE' SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTHXY LINEAR FT r>'- 3 Zf REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT f J ti 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. 1_ OPERATION PERMIT vJ ` \ SYSTEM INSTALLED BY: � (1 V+'t ' Q_ U a d l� -'�' ` / I r UTHORIZATION NO. 60 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. DC.'HD 07/02 (Revised) :'i lit Dell i� qoq Need 4o. DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ��c� APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAM ADDRESS / / J 1 r(]IZK. - Di _ PHONE NUMBER ��0' ��65 - ti/C.�d 0% _SUBDIVISION NAME ,/ LOT # DIRECTIONS TO SITE 6 � fdx D O /11i1e3 Fd r1C 4' d L2 S dIifee I1 e toss S1 o � -Ihe ENd d,'A/Zl("latiol /do( Nhl -e &3,f DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY hSe- NUMBER BEDROOMS 0� NUMBER PEOPLE SERVED o TYPE WATER SUPPLY e0wily SPECIFY PROBLEM OCCURRING I� ,SVS�2fN /d tack ,,d 111ye 440iy iNAO wddds DATE REQUESTED /6 4 INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, d that un06 SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. ,rya I am responsible for all charges incurred from this application. ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section . Soil/Site Evaluation APPLICANT INFORMATION Account #: Billed To:, Reference Name: Proposed Facility: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: Date Evaluated: oG. 75)A�l Community Evaluation By: Auger Boring i/--, — Pit Public�� Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Slope % 91 HORIZON I DEPTH I. Texture group Consistence Structure Mineralogy•` HORIZON II DEPTH it Texture group Consistence Structure Mineralogy.r HORIZON III DEPTH Texture groupS n �� Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: 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 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 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 CC : "'::CCCCC:CCCCCCCCCCCCCCCCC:::::C ::C:C MOORE in WOMEN EMEMMOMEMMIN smommumm C•■ C m■CCMINE ::C:C:CCCC:CCCCCCICCCC:C:::CC:C:CC:CC:CCCCCC::::CC::A �0�.: Cnommmu mommoo:CCCCCCC':CCCCCC".C:C:CCCC::CCMENOMONEE NCC: ■■■..■ CCM.M■..m.■a■m■...a■C■■.■■............................■■C •no••CC'��■.:ommm:mumommomommo:::: :C:CC::CC::::C:::::C:CCCC::NUNN ::'C:�i�':CCC::CCC:C:CCCCCC:Ci:iii:CCC:CC:eCCCCCCCCCCCCCiiiiiC'iCCCi :■ ■■ ■.■.■■..■.■■■■.■■■■.■..■■■■■■■■■e■■.■..■■■m■■■■nae■■■■■..■ C:C..■■■■.■■■.■■......................■........ 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