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1669 Jericho Church Rd�Permittet' DAME COUNTY HEALTH DEPARTMENT Name: zt, ' l Environmental Health Section PROPERTY INFORMATION �� — � P.O. Box 848 Directions to property: d EIL I'Mocksville, NC 27028 Subdivision Name: CPd Phone #: 336-751-8760 Section: AUTHORIZATION NO: 003031 A Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# 5%27- �%� _ DG/Z SYSTEM CONSTRUCTION Road Name: I41,01JO k d -W Zip: Z767r **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 Pennits. (In compliance with Article 11 of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ` IS AUTHORIZATION FOR WASTEWATER CONSTRUCTION J /)/�Q�***NOTICE*** THIS 0 IS VALID FOR A PERIOD OF FIVE YEARS. AL HEALTH/SPECIALIST DtYTE ISSUED ,Pe=inttee_'s /� DAVIE COUNTY HEALTH DEPARTMENT `Name:. /P 0Z1W i��d ��(.!!�� Environmental Health Section P.O. Box 848 PROPERTY INFORMATION Directions �t ' property: lL!' jh l �� e �� d Mocksville, NC 27028 Subdivision Name: r Phone #: 336-751-8760 - AUTHORIZATION FOR Lot: WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# 72 7 - AUTHORIZATION NO: 003031 A Road Name: IA / Zip: ✓ " �! 1"' **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 FonrdAuthorization 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) e 1 { y ,{ �J ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �N )V(t U+(/�6%t:' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTY SPECIALIST D TE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE A� # BEDROOMS J__ # 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 ! � I�( DESIGN WASTEWATER FLOW (GPD) 3Y_ 0 NEW SITE REPAIR SITE LoO'l V ��//f SYSTEM SPECIFICATIONS: TANK SIZE AL. PUMP TANK GAL. TRENCH WIDTH 3_ ROCK DEPTH[ ,, o LINEAR FT. 200 OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 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. 0 OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO.3Q3- 1 k OPERATION PERMIT BY: I i! f' / f DATE: ✓/l! t '� "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESC IBED 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 02102 (Revised) 9ee.1ssb 7 . Fn a • 1315 ;i AUTHORIZATION NO.3Q3- 1 k OPERATION PERMIT BY: I i! f' / f DATE: ✓/l! t '� "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESC IBED 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 02102 (Revised) 9ee.1ssb 7 . Fn a • 1315 DAVIE COU "ePernuttee s fi`� , i NTY HEALTH DEPARTMENT Name. 1 1 f '� ' Environmental Health Section P.O. Box 848 PROPERTY INFORMATION Directions to property: Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 AUTHORIZATION FOR Section: Lo[: WASTEWATER Tax Office PIN:#! Y SYSTEM CONSTRUCTION - - AUTHORIZATION NO: 003031 A Road Name:.` Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior k to issuance of any Building Permits. This FornVAuthorization 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) YIN / / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION A tI cl��0!E`�C l% IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALT14 SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE I/ # BEDROOMS —I— # 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 �I�� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE 1 SYSTEM SPECIFICATIONS: TANK SIZE !" AL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 00 ' REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 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 PERMIT4'/,a I SYSTEM INSTALLED BY AUTHORIZATION NO. '30 .7) f'r. OPERATION PERMIT BY: 01 DATE: THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 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. DCHD 02102 (Revised) !//'/ P`' »—•'1 % :, 41 - •`?- f ,._ Y My i AUTHORIZATION NO. '30 .7) f'r. OPERATION PERMIT BY: 01 DATE: THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 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. DCHD 02102 (Revised) !//'/ P`' »—•'1 % :, 41 - •`?- f ,._ Y - . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION -no"f P"� 166q 3-eri the c, W Aod(roitlt AJ( )0.?t Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit PROPERTY INFORMATION Public I/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % v HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH /0.!//0 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: S LONG-TERM ACCEPTANCE RATE: REMARKS: [---VALUATION BY -.1flup, 11 M11 • .. an 1 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 Maht VFR - Very friable FR - Friable F1- 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 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 05105 (Revised)