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� AUTHORIZAT�ON No: � 7�'� DAVIE C UNTY HEALTH DEPARTMENT ' : -
' "�" � ' '� nvironmental Health Section " PROPERTY INFORMATION
Permittee's' ' ;� P.O.Box 848 .
Name: ' � ,Mocksville,NC 27028 � Subdivision Name: '
4 /
.,.. . . , � � ,J Phone# 336-751-8760
Directions to property: �°' �%i''•� ./'''�'' � Section: Lot:
AUTHORIZATION FOR ' `
WASTEWATER � ,�+ �
' ��F ,P'�� Tax Office PIN:#�^-�� �� =_���
SYSTEM CONSTRUCTION . cy
Road Name: /�c� ��-�'��sb�'Zip; � /l1c�a
**�iOTE**This Authorization for Wastewater System Consuuction MUST BE ISSCJED by the Davie Counry Environmental Health Section prior �
to issuance of any Building�i'ermiGs:This FormlAuthorization Number should be presented to the Davie County Building Inspections
Office when aPPlying for Building Permits., '
, (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ' ' •
, �,� . , , .
/ ,r � ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '
7� ...�„�t``�L, , t . , ��` �� ' IS VALm FOR A PERIOD OF FIVE YEARS.,
• ',ENVIRONMENTAL HEALTH SPECIALIST:" DATE`ISSUED' `' " '� `• ;`
�yx � — s.r ,�w y..:.�. .j� � -� ' �. ' ..r .,�.. .e �rt v.i.. �.,�.ri v„y.�,Ex.�.
�';'.��� �..� ,� �- i �` �d I I ��''�lF� l0.'3U S/3 `1`� -
.' � r ' ;" �� '� ,��� . DAVIE UNTY HEALTH DEPAR7''M�NT , , �
� �",�'b''� j� ,��•'. '� � IIVTPRO�EMENT AND OPERATION-PERMITS PROPERTY INFORMATION
`Permitt�e;s -J'�Y ,,: "---�;'" . � �, ' `� . � - � , , _
rv'Name:� � ' ��_ � - Subdivision Name:
� r� �_: ,r'�
Directions to property:`�`_� �'� l ;vr ' �- Sechon: ' Lot:.
,. IMI'ROVEMENT. , ._ � <� _. �� _ '`r���
�,%','x,',J ,�`i'`�� �� PERMIT Tax Office PIN:� �,_
Road Name• /�� �/ � �' s�Zip: � �����
. , .. . - , , _
.' ' **NOTE**.'This Improvement Pernuf DOES NOT authorize the construction or installa6on�of a septic tanlc system or any.wastewater system.An
� '.` •AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Departrnent prior to the ; `
. construction/installation of a system or the issuance of a building pernut. ' ' '
(In compliance with Aiticle 11 of G.S:Ghapter 130A,VJastewater Systems,Section.1900 Sewage Treatment and Disposal 5ystems) :�,
' � .� ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION 1F SITE . '
' ���'�^� �'± � � E f r>�'� , �," t ••�•.''` SYSTEM ONTRACTOREMUST SEEATI-Q�ERMIT BEFORE �R ;
f,.
-.ENVIRONMENTAL HEALTH SPECIALIST. � DATE ISSUED � INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION.BUILDING TYPE� #BEDROOMS S'`#BATHS.�S`�#OCCUPANTS,��GARBAGE DISPOSAL:Yes or No �
COMMERCIAL SPECIFICATION: FACILITY TYPE` #PEOPLE #PEOPLFJSHIFI' #SEATS ` INDUSTRIAL WASTE:,Yes or No `
LOT SIZE � TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE_� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/DGY� GAL. PUMP TANK GAL. TRENCH WIDTH'..�L ROCK DEPTH ��'LINEAR FT D6�
.
OTHER f� � ��1 f'(.i��� �
, .
'. -�,� —
. _ , , . . .
; REQUIRED SITE MODIFICATIONS/CONDITIONS: �
IMPROVEMENT PERMIT LAYOUT ' . .
,;.:. . , , . : . . ; , , r�
.
, . _
,. _
�.__
, ..;' � ,:. . .
, .,.,.;. . ;. , .-.. � ., . . - . � .. ,.. . ... .. r :,�. _..� .. .. ,. .� ,. ..,, ' .....
,' ,',�� .�. . . : � . .' .
, �. . , , - � � . ' .. .
:. .... . . . .
. ; .�.• � . �; �� . . .: ` '. .. ... . . . . .... . �. ..�. � �" � , � .. . � .
. . . . � /� �� . . � � � ' �
rs ,. IE COUNTY HEALTH DE , _ � �
CONTACTA'REPRESENTATIVE OF THEDAV PARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
> . BETWEEN 830-9:30 A.M:OR.1:00-1 c30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751=8760. ;
OPERATION PERMIT . _ , •
�� SYSTEM I TALLED BY: ��� �
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I�J Q
.
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AUTHORIZATTON NO. '��OPERATION PERMIT BY: ` DATE: �I��!
�-
*'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
W1TH ART'ICLE'11 OF G.S:CHAP'TER 130A,SECTION.1900"SEWAGE TREAT'MENT ANDbISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A` :
GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCFID 05/96(Revised) '
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` 1 ' /V V '�/ �/��//Y/`� �/��I�y✓ l ��/��
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'- M�� ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT � �'"�'�'�
`�" Davie County Health Department � � �� �S
p'� � ,L �_ r Environmental Health Section
� �W�� � P.O.Box 848 ,� -4 lgag
��� 1� � .� Mocksville,NC 27028
��r��� �� � _ ,.,� .�f,�.
) I l3367751-8760 �;�3;;Us, ��7�.�.t„�,�,,,�
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED IsLB `+� '� �� -
r���X ALL THE REQUIRED INFORMATION IS PROVIDED.
� �t��l J�<'nn i 'k�h
1. Name to be Billed � ��1� Contact Person ��V FrlCr}� �
Mailing Address �� �O)C �3 / Home Phone �`o �``��S
City/State/Zip �d���C�'/Vl � �C �7� �N Business Phone ��0�79-�s C1
2. Name on PermidATC if Different than Above ��
�� __
Mailing Address City/State/Zip
1 �!i ou.A.r _ �a-,2�9
3. Application For: l� Site Evaluation �Improvement Permit&ATC ❑ Both
I -
4. System to Serve: � House ❑ Mobile Home ❑ Business ❑ Industry '� ❑ Other
2 ai
5. If Residence: # People J # Bedrooms � , # Bathrooms ?
❑ Dishwasher ❑ Garbage Disposal J�Washing Machine ❑ Basement/Plumbing �Basement/No Plumbing
6. If Business/Other: Specify type "- # People r # Sinks ~
# Commodes ^ # Showers r' # Urinals ` # Water Coolers '�
If Foodservice: # Seats � Estimated Water Usage(gallons per day) '-
7. Type of water supply: ❑ County/City k�Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes � No
..-,
If yes,what type?
Z
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A P�;�THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: /O�� � WRITE DIRECTIONS(from
Mocksville)TO PROPERTY:
Tax Office PIN: # J�7 C.f�-�'� = L - � Q���P,
/'^ �� � rno c�
Property Address: Road Name ��Qli��S�
1
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City/Zip rl S UI�� �
� �� S� �%/VC
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If in Subdivision provide information,as follows: 1 •
1 fJ�( W i S' O�''�
Name: �� �
� -�I C�YV�
� '
Section: '''� Lot #: '—' � ��'�'
� �sr ord �,z
This is to certify that the information provided is correct to the best of my knowledge.I understand that any pernut(s)issued hereafter
aze subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is
falsified or changed.I,also,understand that I am responsible for all charges incurred from this application.I,hereby,give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by �/Ke ��/5 ' to conduct all testing procedures
as necessary to deternune the site suitability. �
, / �
DATE [�� `7"� � SIGNATURE
Revised DCHD(06-96)
l�fOU MAII�J USE THE $�tCK O� THZS �ORM �OR bIZAWING iJOUIZ SITE PL,4N. A ► � , �'�'9
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� '' � • DAVIE COUNTY HEALTH DEPARTMENT
'r" ' ' Environmental Health Section
Soil/Site Evaluation
NAME /)�`� � DATE EVALUATED '��"��
ADDRESS . PROPERTY SIZE ,�AC ,
PROPOSED FACIILTY LOCATION OF SITE .�'7y1,�'!J C/`o� I
Water Supply: On-Site Well �,.�_ Community Public
Evaluation By: AugerBoring Pit Cut
FACTORS 1 2 3 4
Landsca e osition
_ Slo e R
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH t' ��
Texture rou _
Consistence
Structure /r/ _
Mineralo :j l��!
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLaSSIFICATION ,S' �-
LONG-TERM ACCEPTANCE RATE , �- , �.
SITE CLASSIFICATION: EVALUATED BY: �C'�/� '
.--
LDNG-TERM ACCEPTANCE RATE: • � OTHER(S) PRESENT:
REMARKS•
LEGEND
Landscape Position
R-Ridge S-Shoutder 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-Vc.-y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely finn
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
,iC-Single grain M-Massive CR-Crumb GR-Granular ABK-AnQular blocky
SBK-Subangular blocky PL-Plnty PR-Prismatic
Mi neralo¢�►
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 watet' 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
� � �
. ,
< < �
'' . , � � �avie County�Cealth �epa�nt
and�Come .�ealth.�.gency
. �nvironmental�feaCth Section
M�F'�� P.O.Box 848/ 210 HosPRn�STaeeT
N�N� ��1� COURIER#09-40-06
�� pNpMP�B�O MocKsviue,N.c.27028
���G-��33�51' PHONe:(704)634•8760
June 23, 1998
Nayrex Smith
R. D. Box 537
�Coolee�ee, NC 27014 �
Re: Site Evaluation
� Knoll Crest Rd.
Tax PIN: #5747-82-4288
Dear Clientts) :
As requested, a representative from this office visited the
aforementioned site on June 19, 1998. Based upon the information
provided on the application for site evaluation and after the evaluation
was completed, the site was found to be provisionally suitable for installation
of an on—site sewage disposal system.
Before a permit can be issued the appropriate application must be filled
out and the house/�obile home location staked off.
If you have any questions, please feel free to contact this office.
, Sincerely,
���� �����
Robert B. Hal l, Jr., R.S.
Environmental Health Specialist
RH/wd
Enclosurets)