225 Glenn Allen RdR.rmitteejs, I' DAVIE COUNTY HEALTH DEPARTMENT
Name: rf LVW1�L F + Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
AUTHORIZATION NO: 002903 A
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - —
Road Name: ! 11• Es 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 DATOSSOED
RESIDENTIAL SPECIFICATION: BUILDING TYPEit , # BEDROOMS t�F� # BATHS # OCCUPANTSGARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
I
LOT SIZE TYPE WATER SUPPLYDESIGN WASTEWATER FLOW (GPD)�f j NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `-1 f ROCK DEPTHITf� J.C_j LINEAR FT. �� LC
Zs`
OTHER'Cl
REQUIRED SITE MODIFICATIONS/CONDITIONS: ' J Iy kg1
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.
OPERATIQ�1 ERhM`IT
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SYSTEM INSTALLED BY: ` -k'
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OPERATION PERMIT BY: ,� b .(�F� 1 M/� DATE:
WANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
`CLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
tE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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Perrrtittee's COUNTY HEALTH DEPARTMENT
��;
Name: � >• �`' '' � � Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
+ Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002903 A Road Name:-:.'- " � : �`'� ;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 I 1 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 D TES( ' ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE f' `; • # 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 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
j - t
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ! !� ROCK DEPTHt`- `� LINEAR FT.J. -} (�
REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 v 0 ',b
IMPROVEMENT PERMIT LAYOUT
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1
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.
OPERATIV, ERMIT
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SYSTEM INSTALLED BY:
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AUTHORIZATION AO. OPERATION PERMIT BY: Ij / i } DATE: 1
•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) -:fl 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.
OPERATIV, ERMIT
�v
��l
SYSTEM INSTALLED BY:
V 17
1 j
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fo 0
AUTHORIZATION AO. OPERATION PERMIT BY: Ij / i } DATE: 1
•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) -:fl a*
APPLICANT INFORMATION
Water Supply:
Evaluation By:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
On -Site Well 'V /
Auger Boring
Community
Pit
PROPERTY INFORMATION
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
(,
Slope %
—TIT
HORIZON I DEPTH
D 2
Texture group
G
Consistence
Structure
MineralogyS
HORIZON Il DEPTH
60
Texture group
G
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
e
SITE CLASSIFICATION: 1
LONG-TERM ACCEPTANCE RATE:
REMARKS:
iI-
EVALUATION BY:
OTHERS) PRESENT: ' 6b l" �11YIUO
�Al S
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
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
3y -d
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 05/05 (Revised)
• DAVI OUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME 6leS PHONE NUMBER
ADDRESS Zz'
A'41-'��Vi)/&—SUBDIVISION NAME
LOT #
DATE SYSTEM INSTALLED , ` � NAME SYSTEM INSTALLED U
TYPE FACILITY
UMBER BEDROOMS
1
UMBER PEOPLE
TYPE WATER SUPPLY-1&8—SPECIFY PROBLEM OCCURRIN
DATE REQUESTED INFORMATION TAKEN BY�-Q iX fYV
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 I Ay W(ll Llo /L /3/V
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Q MAPS - Davie County NC Public Access
Davie County, NC - GIS/Mapping. System
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DAVIE COUNTY HEALTH DEPARTMENT
SEPTIC TANK PERMIT Date
)caner/Occupant
To:
Address
Address
Building ContractorP
Address
almanufacturer's Name
Address
-N
No. of linesWidth LJ n . Toal length
22
ft. No. sq.
ft.
Type of filter m a t e r i a 1
Total tons used
!,!inimum REquirements: House Trailer Tank
cap. 800 Sq.
ft. line
400
Two-bedroom house
800
600
Three-bedroom house
900
900
No one shall install a septic tank in Davie County without a permit from the Health Offi(
or his agent.
Date of Final Approval
Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to specification
Signed: 61?111411�
Septic Tank Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.