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735 Burton Rd r - 3 44,COP Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 loo. U O - Mocksville, N.C. 27028 ` = AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (lssuedlin compliance with Article 11 of 116.S. Wter 130A, Wastewater Systems) ***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Sktion prior to ti issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Offfi`ce` when applying for Building Permits.*** NAME W A��CeP b- � ' �\ twR DATE �' I�." AUTHORIZATI1jO;N NjUM®ER. 0A, o NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION COIENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM �? Yi **WICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95 Z, _� e .. ,_ S..s i x _' - � "�t� ..r DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or.any wastewater system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of 6.5. Chapter 13OA, Wastewater Systems, Section .1906 Sewage Treatment and Disposal Systems) NAME \1J�1''Ce c�kQN N R W 1 W 0 R PROPERTY ADDRESS Ll N a� 7d a�o DATE LOCATION LA - - Or ct a� �e.� Or dr. %aNIF, SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE SQ # BEDROOMS # BATHS . # OCCUPANTS GARBAGE DISPOSAL: Yes Po COMMERCIAL SPECIFICATION: FACILITY TYPE J�'` }rU # PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes/Noy, rt f LOT SIZE u X 6�, .TYPE 1JPTER SUPPLY '' DESIGN WASTEWATER FLOW (GPDY �U r NEW SITE ` - REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE CSD GAL PUMP'TAW GAL. TRENCH WIDTH 3 ROCK DEPTH ��i1 LINEAR'FT. OTHER ,F REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS'OR THE INTENDED USE CHANE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE.SYSTEM. IMPROVEMENT PERMIT BY Cy **CONTACT A REPRESENTATIVE OF THE DAVWCOUNTY'HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 1:00-1:30 P.M,,;ON THE DAY OF, INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BYt T 0 Y doe AUTHORIZATION NO. RATION PERMIT BY DATE **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 13OA, SECTION .1900 -SEWS 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 10/95 AN �• , DAVIE COUNTY HEALTH DEPARTMENT -: , IMPROVEMENT PERMIT and OPERATION PERMIT i IMPROVEMENT PERMIT **MOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME 1j '1\ k%f7tnx 110 is PROPERTY ADDRESS ; T) 19(0 DATE LOCATION SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE v ya # BEDROOMS # BATHS , # OCCUPANTS !� GARBAGE DISPOSAL: Yes)No COMMERCIAL SPECIFICATION: FACILITYTYPE `} �:�a # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No-, LOT SIZE U'A'�JGP TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GRD) to UNEW SITE ✓REPAIR SITE' SYSTEM SPECIFICATIONS: TANK SIZE 6AL. PUMP TAM( GAL. TRENCH WIDTH 7`..1 ROCK DEPTH LINEAR Vii' LINEAR FT OTHER w__ REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST ,.,,SEE THIS PERMIT BEFORE INSTALLING THE.SYSTEM. 1UV 1 l IMPROVEMENT PERMIT BY **CONTACT A REPRESENTATIVE OF THE DAVIE"COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:38-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY. ti f i V� 10 0 , o AUTHORIZATION NO. RATION PERMIT BY DATE (gAd IK **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 FUJNCTION SATISFACTORILY.FOR ANY GIVEN PERIOD OF TIME. ,."bCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE l7 z Davie County Health Department Environmental Health Section FOEC, 74T P. O. Box 665 Mocksville, NC 27028 � � r 1. Application/Permit Requested ' t rrJG;-ft /'• c� Mailing Address ✓ Home Phone 9/d 91 P 74160 i5X7 OX Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation G<eptic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision �- Section �—Lot # �- 2-1 a ement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms 3 O'Washing Machine No. of Bathrooms 2 ishwasher Dwelling Dimensions 3 / x a-00 , ER011rarbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: / ElPublic / r� ivatte ❑ Community 8. Property Dimensions { 0 .Of id Ou O-�Sewage DiVspwos'arl�Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes &40 If yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plana or the intended use change. Effective October 1, 1989. Directions to Property: pt o,v le S C re e JZ X2/0'1• r f hr w. Re.aw les Gr We e,fu /3u e, �. U or. 2''o ha" �2 A ,'/es f o q 1 M Po oe m-e'� -1 Lo � e Ph, 9' c This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this applatios 3 DATE SIGNATURE CONSENT FOR SITE EVALU6MN TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: IZ 1/. I OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized represent tiyye QQf the D. County Health Depart ent to e_r�ter upon above described cated in Davie County and owned by, r/��r A f //vvGTTd E A'In OY all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment system. 94 DATE SIGNATURE DCHD(1/93) . LA _ r � X90 ` � y . DAVIE COUNTY HEALTH DEPARTMENT s Environmental Health Section �Soil/Site Evaluation NAME ��� �NN F \>e \ �l �`� DATE EVALUATED 12 - 1 ADDRESS � W`i . _ PROPERTY SIZE PROPOSED FACIILTY O o LOCATION OF SITE . _tip Water Supply: On-Site Well (/ _ Community Public 1 Evaluation ByC,c"r_1--Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position S Sloe % - 5 s3 -I � --1� HORIZON I DEPTH 4 Texture group C L 1 L Consistence Z FZ Structure e Mineralogy HORIZON II DEPTH Texture groupC Consistence 1-�- Structure Mineralogy ' ) HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE — CLASSIFICATION ,S • S. , LONG-TERM ACCEPTANCE RATE t I SITE CLASSIFICATION: �`5' EVALUATED BY: � � LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LE ND 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 :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Ve.-y 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 Mineralo+ 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(01-901 ■■■■■■■■■■■■■■■■■■■■■,■■■■■■■■■■■■■■■■■■■,■■■■■,■�1■■■e■e■■ ■■MOON■ ■■■■■■■/■■■■■■■■■NOON■N■■■■■■■■■■■//■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■,■■■■■■■■■■,■■,tNEN,■■■■■,■,■■■,■■■,■,■■Nee■■■■■,■,■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■NOON■■■■C■■■=■■■■�■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t■■■■■■■■■ ■■■ NOON ■■■■■■■■■■■■■ ■■■■■■■■■■■■■//■■■/■■/■■■■■■■■■■ N■■■/■■■■■■■■■■■ Ee000000■■■Oo■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC ■■■■■■■,■■E■■tMoo■■■■■■OOOEE■OOOO■OOt■■,■ ■■■ ■ ■ ■e■ ■■,■■■ ■■ ■■■■,■■■■■■■■■■■■■■■■■■■■■■OOEEo■■■E■■O■ ■■, ■ ONE momommm ■■■■,■,■■■,e■,■■o■■■■■■■■■■■e■■t■■,O■e■Noe■■Noe■N e,■ee■E■■■e■■■■■ ■■■■■■■■■■■OOON■OO■■■■OOO■■e■■N ■o■■■o■oeo■■,■■o,■■■e■e■eNeo■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCi moommomommooii0 CCCCCCCCCCCCCCCCC\ '\CCCCCCCCCCC'■ \=CCmmommommmom1eio■CCCCCCCCCCCC=C CCCCCCCCCCCCCCCCCCC����CCCCC■:CCCC\�CCCCieC��sCCCCCCCCC�■CCCCCEN ■■■■■■■N■ee■■■■■■■■■■■\'1�■■■■■■�■■�■■■■N�\NINONN■■,■■■■■■OC■ON ■■■■■■■■■■■■■■■■■■■■■■■■■\\■■■,■ ,e.■■■■■ ■� n■■Nee■■■e■,■■■■■ ■■■■■■ENOOEOOOOO■■■■■NO■■\�O■t■■oONi■■■etOONCoO■■C■■E■■eo■EE■C ■■■■■■■,H■■e/��■■■■■■■■■■■■■■,■■■■O■■■■■■■tut■■ �e,■■ ■■,■,■ ■ NOON■■■eee■eee■■■■\■■■eee,■■e■■■■■■■e,■„■�,ee■■■ oeee ■■e■,■■■■■ ■OE■„■,■■■■■,■t■,■■\r■,■■■,■,■L1■■■■■e■■ ■■■NONE ■oo■■oeCoo■■■■■■ ■■■■,■■■,■■■■■■■ Jwl1■■■■■■E■�■■��[! .�a,� ■■eeee ■■Nee■■ Neo■Eo■■ ■■■ H■,■E■,NE■■r.�■►■■„■i�e■■iii ■■itCC■e�l•■,CC ■H,n C ■■■t■■■ ■■■,Cee,eee■oeee■��e►�■■,eeei�eoo�eeee■ee� .�►e■eeC■ ee■NN C■■■■■■ ■■■■/■■■,■■■■,■■/►�■.�r.■■■■■��■■►:.«e� . ■ 'C w i ■ NNE mom ■■„oeeoe■eoeee■e1►�..■ e■■,■e■e■ 117a C ■■■■■■■■,e■■e■■e■e■■t■■eee■e■ee,�■■�■,� e►�►►u n■■ ■C0e,■■,C uNOON■■ NOON■■ NN■Ne, ,eNE,I� , ■■,E� ■_�■'CC ■■CC ■■■■■■ . ■o■■o■�o■■o■O�■■NE■E� eoON110N!■„I ■ ■ ■■■■�OoNEo■ ■■■■000O■■H■e000■■,■en■■CI11■ENII■ENl.ee' oo■e0000■■■■ .......■■■eee,oe■ee,oee,e■e�eeelle■.iH er�- e■ ■o■■■e■■ ■■■■■■■■■■■a■H■■■■E■■■E■■■■EN■11 ■� �� ■ ■■ EN■■ ■■ so CCCCCCCCCCCCCCCCCCCCCCD "a::::�' : : . 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