583 Fred Lanier Rd**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
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LOT SIZE �' TYPE WATER SUPPLY l� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE ,GAL. PUMP TANK r AL. TRENCH WIDTH ROCK DEPTH LINEAR FT. )o O
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT ,
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 --39 0'A -M ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
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AUTHORIZATION No�bIb OPERATION PERMIT BY- DATE:
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"THE ISSUANCE OF THIS OPERATION PERMIT SHALL 3INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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)
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Permittee'sj�
i DAVIE COUNTY HEALTH DEPARTMENT
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Environmental Health Section
PROPERTY INFORMATION
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P.O. Box 848
Directions to property:
Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760
Section:
Lot:
AUTHORIZATION FOR
WASTEWATER
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Tax PIN:#
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SYSTEM CONSTRUCTION
,Office
AUTHORIZATION NO:
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Road Name:
Zip:
**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
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LOT SIZE �' TYPE WATER SUPPLY l� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE ,GAL. PUMP TANK r AL. TRENCH WIDTH ROCK DEPTH LINEAR FT. )o O
OTHER Q f
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT ,
/
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7 -�
t
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 --39 0'A -M ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
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AUTHORIZATION No�bIb OPERATION PERMIT BY- DATE:
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"THE ISSUANCE OF THIS OPERATION PERMIT SHALL 3INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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)
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
...NV 1 lUL— I H16 AU I HORILA I R)N t^UK WANT EWA' EK CONN RUC ION
F IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST" DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE -'` # BEDROOMS a # BATHS -) # OCCUPANTS I- GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE /' f 5 TYPE WATER SUPPLY (� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE / GAL. PIMP TANK "/ AL. TRENCH WIDTH `^ ROCK DEPTH LINEAR FT.
OTHER U 1 U�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT a�
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 930. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
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AUTHORIZATION NO.�bOPERATION PERMIT BY:,k", i� DATE: / l
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**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INlKATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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)
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DAVIE COUNTY HEALTH DEPARTMENT
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Environmental Health Section
PROPERTY
INFORMATION
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P.O. Box 848
Directions to property:
Mocksville^ NC 27028
Subdivision Name:
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Phone #: 336-751-8760
Section:
Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
Tax Office PIN:#
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Zip: C•
AUTHORIZATION NO:
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Road Name:
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**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
...NV 1 lUL— I H16 AU I HORILA I R)N t^UK WANT EWA' EK CONN RUC ION
F IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST" DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE -'` # BEDROOMS a # BATHS -) # OCCUPANTS I- GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
r // --5
LOT SIZE /' f 5 TYPE WATER SUPPLY (� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
r 1, 1-�
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SYSTEM SPECIFICATIONS: TANK SIZE / GAL. PIMP TANK "/ AL. TRENCH WIDTH `^ ROCK DEPTH LINEAR FT.
OTHER U 1 U�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT a�
V
JI
r
\VI I
r
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 930. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
} `OPERATION PERMIT a R -e V � A
� SYSTEM INSTALLED BY: l CSG ►t '111114 I',l
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AUTHORIZATION NO.�bOPERATION PERMIT BY:,k", i� DATE: / l
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**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INlKATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900414 Tax PIN/EH #:
Billed To: CGc�t�� 4ci1�1e__ Subdivision Info:
Reference Name: Location/Address: j
Proposed Facility: Residential Property Size: A vs Date Evaluated: `'f
2 7 �-
Water Supply:
Evaluation By
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On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
V
Slope %
HORIZON I DEPTH
Texture groupC
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
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LONG-TERM ACCEPTANCE RATE
•
SITE CLASSIFICATION: / .�)
LONG-TERM ACCEPTANCE RATE: -7 5
REMARKS:
LEGEND
EVALUATION BY
OTHER(S) PRESENT: `— •� U�
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 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)
TTAR - T.nnv-tP.rm ArrPntnnrP rntP - onl1rinuifti T,nT TT% nC/nc /T
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER -LIP -021 � v
ADDRESS §q3 t"rt-d Lary ,r P01 SUBDIVISION NAME
LOT #
DIRECTIONS TO S
I -41 a
DATE SYSTEM INSTALLED D f S NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY `n t 1 SPECIFY PROBLEM OCCURRING
+h! 1 i i h I< n &* t- — P n n -ko � 1< ccrcJ rj -i : ri 1. n l L4 y
DATE REQUESTED INFORMATION TAKEN
This is to certify that the information provided is correct to the best of my knowledge, and�pYyindand I am responsible for alges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93