1680 Deadmon Rd. . _ . . . . �� . . . _ -�� , - ' � _ . , . . -. , � � � . , . .. � ' . � // ' .
. . .� . .. vi �. ♦ ,� ' �'Y a.. .'. �` I
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AUTxoxizATiorr No: Q 7 � � DAVIE COUNTY HEALTH DEPARTMENT •� ,f r'�� �
, � ;..:. .. �.,
�'• Environmental Health Section PROPERTY INFORMATION
Permitt�e's�--��' .yj P.O. Box 848
J�`
Name: �=.����%'' Mocksville, NC 27028 , Subdivision Name:
b -� �!`�.�.7,� �? Phone #: 704-634-8760
Directions to properfy: ���� r�-...- Section: Lot:
AUTHORIZATION FOR / )
�� �,E;,,,�-.,,� �..�._,,,, WASTEWATER Tax Office PIN:# �rl��)- !n � - � � 'n �
SYSTEM CONSTRUCTION
Road Name: ��/i �YYI D n! ��ip: _�, r� �
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pernuts. �
(In compliance with Article ll of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
��,�' ;J ,1 ('� ***NOT'ICE*** TFIIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r`" J' -�t ,I t, ; f� 7 rJc'',�,`� /��}. /�r IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEAL�"H SPECIALIST DATE ISSUED
. . . .,,.,. �' , . �.;�5 . . .. .. . . ... . .. . . .
�a
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' . '; �, . -`_ I , ;. L Y^ DAVIE.COUF `� �v �`, .
F�' NTY HEALTH DEP` RTMENT - f "`}'� -
_ ' "�. � ' . -; �" ' IMPROVEMENT AND OPERATIO PERMITS PROPERTY INFORMATION �
�, 17
• Permitte�c���s. �: �: / .. ,r� /
�Name ` .:,��t1,�?i) / �?�?_lE��'..
r - ,
" . �- . �y "7"`� < : ? t %� f r�...
Directions_to properfy: <--` �" •.—% ��t--�-
� '� ! C w�.- -. ,,..t...
-. � _,. ' �" � �.� E � -.-
Subdivision Name:
Section: Lot:
IMPROVEMENT : �
PERNIIT Tax Office PIN:# � �`=� �t _ � - ' : - �� `' �`'�T
i
Road Name: t=�`� C? �?l'1:'} � t� y�� .�,Zip; {`i f''' `->, �;'
**NOTE** This Improvement Pernut DOFS NOT authorize the construction or installadon of a septic tank system or any wastewater system. An
p AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIQN must be obtained from this Department prior to the
construction/installation of a system or the issuance of a buildirfg peimit. ' -
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** TFIIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�` 1 {';; �',�• <<, ;' `� ,,.�';-" 1 s ji�;�_ PLANS OR Tf� IIV'I'ENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THI.S PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �+� # BEDROOMS "�` # BATHS i� # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFf # SEATS INDUSTRIAL WASTE: Yes or No
i
LOT SIZE��`% �,�" TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) `:�G .-% NEW SITE L� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE � I� GAL. PUMP TANK GAL. TRENCH WIDTH -.�/� � ROCK DEPTH � LINEAR Ff. '=��t 0�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
LAYOUT
*'"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY 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 BY: �eo�S
��5 �
�� �N�L" .t°$ 4�
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LL N t� Up i
c�Pi.c;-�-L� �lT
ra�P�C
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�
AUTHORIZATION NO. ��� � OP TYi���' 0 Y: DATE: I�
**THE ISSUANCE OF THIS OPERATION �L IND CATE THAT THE S S DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SE 1900 " WAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
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• .� >� DAVIE COUNTY HEALTH DEPARTMENT
-„ � Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME l�,���Le'i" DATE EVALUATED �`�1`"��
PROPOSED FACILITY ld' PROPERTY SIZE /�'''� �
SUBDIVISION ROAD NAME �� �
Water Supply:
Evaluation By:
FACTORS
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
On-Site Well Community
Auger Boring �� Pit
SOIL WETNESS
RESTRICTIVE HORIZON
CLASSIFICATION
�
1
0
�
Public ��
Cut
3 4 5 6 7
SITE CLASSIFICATION: iJ� EVALUATION BY: ��a; /�
�T
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
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 - Subangulaz blocky PL - Platy PR - Prismatic
Mineraloev
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restric[ive 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 - gaUday/ft2
DCHD (01-90)
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