121 Frost Rd**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)
�( /,ra.,• / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON ENTAL EALTH SPEL'IALIST DAtFE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE j()(7?t# BEDROOMS t�S # BATHS —j— # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �GrlyrE WATER SUPPLY `-" - + DESIGN WASTEWATER FLOW (GPD) � � NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �, ROCK DEPTH 4--1\
LINEAR FT.'
0THFR 4 166] �� L.: -PP �'_.TiC„ 1 4 Ti�n�l ftl.�r. �L�ill�� 7-LUw /ALt/�
REQUIRED SITE MODIFICATIONS/CONDITIONS: T i' 1�1 t �1 i— (� t 75�� I Ut C� �� L I' • I —� tJ=
IMPROVEMENT PERMIT LAYOUT
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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
4
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AUTHORIZATION NO. OPERATION PERMIT BY:
S T I TALLED BY:���
1
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"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPO SYSTE:
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
TE: � l !�
A BEE STALLED IN COMPLIANCE
, BUT SHALL IN NO WAY BE TAKEN AS A
Permittee's t �_
DAVIE COUNTY HEALTH DEPARTMENT
Name: * `'�" 4 1
t-
Environmental Health Section
PROPERTY INFORMATION
1'.7 ,•
_
P.O. Box 848
Directions to property: 1
-=
Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER
Tax Office PIN:# - -
SYSTEM CONSTRUCTION
AUTHORIZATION NO:
0 0 2 C, 7 13,A
Road Name:. -- l f r `- `1 f 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)
�( /,ra.,• / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON ENTAL EALTH SPEL'IALIST DAtFE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE j()(7?t# BEDROOMS t�S # BATHS —j— # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �GrlyrE WATER SUPPLY `-" - + DESIGN WASTEWATER FLOW (GPD) � � NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �, ROCK DEPTH 4--1\
LINEAR FT.'
0THFR 4 166] �� L.: -PP �'_.TiC„ 1 4 Ti�n�l ftl.�r. �L�ill�� 7-LUw /ALt/�
REQUIRED SITE MODIFICATIONS/CONDITIONS: T i' 1�1 t �1 i— (� t 75�� I Ut C� �� L I' • I —� tJ=
IMPROVEMENT PERMIT LAYOUT
�!~
Ns-Oj
I,j
n-1^vu
Lms, `II`rU
\..��J�� ^i-►� I
YS IG S[k&t 1_.D17
ASStgl�
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
4
z FLoQ
AUTHORIZATION NO. OPERATION PERMIT BY:
S T I TALLED BY:���
1
I ,
vA>.
. io
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPO SYSTE:
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
TE: � l !�
A BEE STALLED IN COMPLIANCE
, BUT SHALL IN NO WAY BE TAKEN AS A
Permittee's DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions -to property: c ! Mocksville, NC 27028 Subdivision Name:
r - Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 0 0 M) 3 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
i I ''rA IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRCINM$NTAL'AEALTH,SPECIALIST DAA E 1 SUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE `"a.# BEDROOMS #BATHS �_ #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE (-"`,r.>. r 1 TY E WATER SUPPLY `- t'�'%J1 DESIGN .WASTEWATER FLOW (GPD) ��, i NEW SITE REPAIR SITE \
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK ' GAL. TRENCH WIDTH ROCK DEPTH N n LINEAR FT. I
OTHER >� -!. �/ �L=S Ax IL-'� l�ll1V�"j �-L. ;,V VA 1_
REQUIRED SITE MODIFICATIONS/CONDITIONS: �L J Ur` ,1-1 t_)t )��%) /L" C" 1 I(—)' �•'� i- I I=U • � �►�
I IMPROVEMENT PERMIT LAYOUT
,ATrAC-*
qs
06,Srt-\'j
I)c�fT H I F3
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
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S, T I TALLED BY: � An
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AUTHORIZATION NO.q OPERATION PERMIT BY:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES BED
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900."SEWAGE TREATMENT AND DISPO�AiSYSTE:
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
/7 r2
BEE IN TALLED IN COMPLIANCE
BUT SHALL IN NO WAY BE TAKEN AS A
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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
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S, T I TALLED BY: � An
1 r
NLL
X
AUTHORIZATION NO.q OPERATION PERMIT BY:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES BED
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900."SEWAGE TREATMENT AND DISPO�AiSYSTE:
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
/7 r2
BEE IN TALLED IN COMPLIANCE
BUT SHALL IN NO WAY BE TAKEN AS A
N a) vw6�'-1 c-1 N e �)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLIICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME v &11N) )us _ PHONE NUMBER
ADDRESS �� MeB � o r hwa SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED '�D
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
C ->I') oc ` iAi L_ u 'J�
DATE REQUESTED COI INFORMATION TAKEN BY (--/ 1
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 charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
Name of Complai
Address
Complaint ABO
COMPLAINT FORM
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
04
Date Received X—kh
Received By
.Telephone
f nn 0
QIV�#,Person Responsible for Com laint —
' Address �� P57-" P
Directions to Complaint -45y A
Date Investigated
Complaint Justified
Action Taken
IN
Investigated By _
Complaint Not Justified
1� JC red,, ew-0 a" L1 2,
�,a`1DLoQf1 �1 �io,cS s) to
Date Environmental Health Staff Signature
(DCHD 1/85)
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiySite Evaluation
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #: Tax PIN/EH #:
Billed To: Subdivision Info: an
Reference Name: Location/Address: Zl
Proposed Facility: Property Size: Date Evaluated: 61
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring oe '�_ Pit
Public +�
Cut
FACTORS 1
2 3 4 5 6 7
Landscape position
L
Slope %
HORIZON I DEPTH -
Texture group
Consistence
5 Q
Structure
Mineralogy
��
HORIZON 11 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 C>
SITE CLASSIFICATION: EVALUATION BY:C
LONG-TERM AC(CEEPT�A1cN�CE RATE: OTHER(S) PRESENT:
REMARKS: v`uC1 '�2 a_1 -r Cd � mot
LEGEND
Landscaae 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
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