140 Hunt StDAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
' Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005777 Tax PIN/EH #: 1509000022
Billed To: Donna Williams Subdivision Info:
Address: 140 Hunt Street Location/Address: 140 Hunt Street -27028
City: Mocksville Property Size: 0.56 Acres
Reference Name:
Proposed Facility: REPAIR
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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.
System Type: S.T. Manufacturer Tank Date Tank Size
Pump Tank Size
System Installed By: k E.H. Specialist:RA�QV)T ' ate:
GPS Coordinate:
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005777
Billed To: Donna Williams
Reference Name:
Proposed Facility: REPAIR
ATC Number: 5842
Tak'PIN/EH #: 1509000022
Subdivision,lnfo:: ,
LocationiAddress: 140 Hunt Street -27028
Pcoietly, Size: 0.56 Acres
;Nr-.,•. Site Type: ❑New Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms Z #Bathrooms_ # People Basement Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats—
Square Footage(or Dimensions of Facility)
Lot Size J % Type of Water Supply: [$County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) Tank SizL. Pump Tank GAL.
�C�',` to
Trench Width 'S � Max. Trench Depth Rock Depth1� Linear Ft. � ^
Site Modifications/Conditions/Other:�e'w
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on,the day of installation. Telephone # (336)751-8760.
1( it C C►,!1
(j Itc laJ
mI�'� ��� i �CIt1l� i �t�E&'d
3 W
1
I .441
Environmental Health Specialist Date:
DCHD 11/06 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005777 Tax PIN/EH #: 1509000022
Billed To: Donna Williams Subdivision Info:
Reference Name: Location/Address: 140 Hunt Street -27028
Proposed Facility: REPAIR Property Size: 0.56 Acres Date Evaluated:
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %.
HORIZON I DEPTH
Texture group
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
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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
MQ1St
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 _
llQtes
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 F�v
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) ////
NAME i2Gt- W IIII arn-S PHONE NUMBER `j&q-
ADDRESS 11 -JO 14W4 A, SUBDIVISION NAME
LOT #
DIRECTIONS TO S
DATE SYSTEM INSTALLED cI 7 NAME SYSTEM INSTALLED UNDER E LS SeII (0) �Ij arn- '
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING a1
! /I h614S i rL 4yn mobilhlitl
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge. a n0bat I understand I am responsible fo_all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT 'y
Rev. 1193 Q
9 1? n o n <-717,7
a,L#' ?<n4nr_ lilt