180 Hunt StPermits =s-"' DAVIE COUNTY HEALTH DEPARTMENT
Name: -�f �01 j' -F Environmental Health Section PROPERTY INFORMATION
/ P.O. Box 848
Directions to property: AA ,�y� � Of /\ 1-r / G Mocksville, NC 27028 Subdivision Name:
Phone #: 336-75I-8760 Section: Lot:
ff �r/ AUTHORIZATION FOR
10 h !+ ct, /V 0(!l �5 � i f WASTEWATER Tax Office PIN:#
Y/"SYSTEM CONSTRUCTION
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AUTHORIZATION NO: 001883 A Road Name: Zi
**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 compljancF 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 2 # 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 446F DESIGN WASTEWATER FLOW (GPD) D NEW SITE REPAIR SITE f/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH G ROCK DEPTH LINEAR F173�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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 r G
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"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'ANI),DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
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Perrrmu DAVIE COUNTY HEALTH DEPARTMENT
Name: -w i`" t f �"+�� r`�' Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: +� �� 01 r1 ' �� Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
:';< 2.11 t, o in Section: Lot:
t AUTHORIZATION FOR
j'rf1 is / , (ta , 1� ,( �1 • y ' r + ' WASTEWATER Tax Office PIN:# ,,1t-rSYSTEM CONSTRUCTION
AUTHORIZATION NO: 002883 A Road �ame: 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 ]sof 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 2 # BATHS e)— # OCCUPANTS _&_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No ,
LOT SIZE _j TYPE WATER SUPPLY ` DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH G ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
I IMPROVEMENT PERMIT LAYOUT
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II 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
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AUTHORIZATION NO. OPERATION PERMIT BY: moi ! s DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 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.
DOW _ j __
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
15�
C 4- ol A/
72 '70'LL
Water Supply: On -Site Well Community Public
tc
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L—
Slope %
HORIZON I DEPTH
62-60
Texture group
Consistence
Structure
' t
Mineralogy
HORIZON H DEPTH'
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
4ail
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
/
SAPROLITE
/
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: J
LONG-TERM ACCEPTANCE RATE a % S
REMARKS:
LEGEND
EVALUATION BY: h ✓�� t •G �7
OTHER(S) PRESENT: J ��
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
Mineral=
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 DCHD 05/05 (Revkecl)