126 Lefler Ln**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 forPuildi ermits.
(In compliance with Article 11 pf G. . Chapter 130 `Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,,.i welf 'f `, ' G� IS VALID FOR A PERIOD OF FIVE YEARS.
t V1RONMEktAL(HEAL-f IF S�ECIALIS-e . D;0E ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE i ��� # BEDROOMS --7�_ # BATHS 2 # OCCUPANTS S' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT
�j �, # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE t `" — T E WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) B (OO NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH A LINEAR Fr. 22-S
OTHER Fti-Q7 L�/o=IJ��f.�OT�r \L! C.7W���^�Ci �L1JhiyfV-y�
%REQUIRED SITE MODIFICATIONS/CONDITIONS: I tJ 5'`nl.l.- o� t
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) 751-9760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
30-t F-cm-y--
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AUTHORIZATION NO.
moo;
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70 __;
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OPERATION PERMIT BY: DATE: /V-73 -07
**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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised) n /�/1 �✓ �� —'r -W016 sv g�v
Pernuttee'sDAVIE COUNTY HEALTH DEPARTMENT
��-`�Ea
Name: -A JT)Y I �1t-#1
Environmental Health Section
PROPERTY
INFORMATION
"UI UV #
P.O. Box 848
Q�z
r
Directions to property: y
,
- i j_ 5
—I
Mocksville, NC 27028
Phone #; 336-751-8760
Subdivision Name:
1
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�
Section:
Lot:
t�._ 't.. � o���- �^J
A+ T i_00 t„>„i'�Y_�,.,,�
AUTHORIZATION WASTEWATER OR
�
SYSTEM CONSTRUCTION
Tax Office PIN:#
- -
AUTHORIZATION NO: 002761 A
Road Name: �'? t"Lt't' 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 forPuildi ermits.
(In compliance with Article 11 pf G. . Chapter 130 `Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,,.i welf 'f `, ' G� IS VALID FOR A PERIOD OF FIVE YEARS.
t V1RONMEktAL(HEAL-f IF S�ECIALIS-e . D;0E ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE i ��� # BEDROOMS --7�_ # BATHS 2 # OCCUPANTS S' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT
�j �, # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE t `" — T E WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) B (OO NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH A LINEAR Fr. 22-S
OTHER Fti-Q7 L�/o=IJ��f.�OT�r \L! C.7W���^�Ci �L1JhiyfV-y�
%REQUIRED SITE MODIFICATIONS/CONDITIONS: I tJ 5'`nl.l.- o� t
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) 751-9760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
30-t F-cm-y--
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AUTHORIZATION NO.
moo;
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70 __;
[00
OPERATION PERMIT BY: DATE: /V-73 -07
**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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised) n /�/1 �✓ �� —'r -W016 sv g�v
**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 Build•_ ermits.
(In compliancewith Article I I of G .S. Chapter 130 ,Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
,/� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
y �i'r'`� ,,� t"�'" \ ,.• '°( IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMVNT'A4HEAL�'i Fi SRECIALIST DATE ISSUED' t
wq
RESIDENTIAL SPECIFICATION: BUILDING TYPE 1 t Se~ # BEDROOMS --a—# BATHS # OCCUPANTS •:*^ GARBAGE DISPOSAL: Yes or No .
COMMERCFIAL SPPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE {'�PE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) &10 NEW SITE--L—REPAIR SITE r�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH " ROCK DEPTH a A LINEAR FT. 22IS.
OTHER &CLJ" 1 G1�
\REQUIRED SITE MODIFICATIONS/CONDITIONS: I t i Jl +=� u- C"s j�I� � t' 10� + t 1 1^"?'*S c:•
s
I IMPikOVEMENT PERMIT LAYOUT
1 ,
1
-- a
FOR FINAL INSPECTION OF THIS SYSTEM LEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
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OPERATION PERMIT
1
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AUTHORIZATION NO. OPERATION PERMIT BY: � DATE: —L13 !67
**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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF, TIME.
DCHD 02/02 (Revised) /1 In -r "J'• v V D l `„" W 1 E (j
Permittee's.
F•`y
DAVIE COUNTY
�'~��- �
HEALTH DEPARTMENT
PROPERTY INFORMATION
N�*�"_ IJ
MGIC
Environmental Health Section -
�' �LL� t
P.O. Box 848
NDirections
to property:
u, I U ,
Mocksville, NC 27028 Subdivision Name:11
(-Phone
'*%
#: 336-751-8760
t)
Section:
Lot:
t L-�((,:. ,•.:ir tWASTEWATER
�Q5
AUTHORIZATION FOR
Tax Office PIN:#
_
002761 A
SYSTEM CONSTRUCTION
r
�`
AUTHORIZATION
NO:
Road Name =-"
'�' ip: '
**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 Build•_ ermits.
(In compliancewith Article I I of G .S. Chapter 130 ,Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
,/� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
y �i'r'`� ,,� t"�'" \ ,.• '°( IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMVNT'A4HEAL�'i Fi SRECIALIST DATE ISSUED' t
wq
RESIDENTIAL SPECIFICATION: BUILDING TYPE 1 t Se~ # BEDROOMS --a—# BATHS # OCCUPANTS •:*^ GARBAGE DISPOSAL: Yes or No .
COMMERCFIAL SPPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE {'�PE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) &10 NEW SITE--L—REPAIR SITE r�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH " ROCK DEPTH a A LINEAR FT. 22IS.
OTHER &CLJ" 1 G1�
\REQUIRED SITE MODIFICATIONS/CONDITIONS: I t i Jl +=� u- C"s j�I� � t' 10� + t 1 1^"?'*S c:•
s
I IMPikOVEMENT PERMIT LAYOUT
1 ,
1
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FOR FINAL INSPECTION OF THIS SYSTEM LEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
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OPERATION PERMIT
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AUTHORIZATION NO. OPERATION PERMIT BY: � DATE: —L13 !67
**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 FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF, TIME.
DCHD 02/02 (Revised) /1 In -r "J'• v V D l `„" W 1 E (j
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a-A1^4F Oif-t 60 'rtiV 3 11-3 lr' oL
• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) �� c
NAME 1�t��il Y--t� w�(C PHON NUMBER %Oi l I U
ADDRESS ZAP UU�'ri_X1'1Q_ _ M SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
SAW
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �T SPECIFY PROBLEM OCCURRING
DATE -REQUESTED ti " INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my ke edge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGE
Rev. 1193
_r'
N DAVIE COUNTY HEALTH DEPARTMENT
T Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring Pit
PROPERTY INFORMATION
Public f
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH n ZZ -
Texture group
Consistence ;
Structure of
Mineralogy
HORIZON H DEPTH
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: EVALUATION BY: al�
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
IYIQiSt
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
Mineralogy
1:1, 2:1, Mixed
1Y41sS •
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 - $(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised)
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DAVIE COUNTY -"HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
- *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems fJf ,r� Permit Number
Name lve- 11114 'i` //,6T-6125- Date _2 No 69,06
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size A) G' House �/� Mobile Home Business _— Speculation
No. Bedrooms L? No. Baths No. in Family—
Garbage Disposal YES ❑ NO d Specifications for System:
Auto Dish Washer YES NO
Auto Wash Ma^hine YES NO ❑
.. Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
F
Improvements permit bY
*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 day of completion. Telephone %mber 704-634-5985.
"
Final Installation Diagram: ste st lled by —
A 0 111fC1 L, P
/''
Certificate of Completion i f Date
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
up
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P R I
Davie County Health Department 1 �9�2
Environmental Health Section SEP
.. P. O. Box 665
Mocksville, NC 27028
I r �
1. Application/Permit Requested By RL c� 1� A -a-5
Mailing Address :R fq� b Y G 7 S_
Home Phone in 3 4- 6 G Business Phone a / 7
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation D -Septic Tank Installation
4. System to Serve: 0 --louse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
No. of People 3
No. of Bedrooms 3
No. of Bathrooms Z
Dwelling Dimensions '92 7.22(4 5
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
❑ Basement/Plumbing
E-Basement/No Plumbing
4;�IWashing Machine
D -Dishwasher
❑ Garbage Disposal
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: El -Public ❑ Private
8. Property Dimensions /41 1,36 4.44 x it,) -aa LUI.5', Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
i
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: Uo f o„�k l"� a r� 1� r+ 00 8 0 1 To j sr C "� `r• Q_ (� s r >3 Q „�
T4 14 t1�,2sey) sc-d. a
w; 1l
S. EF SVr-k< v � �-
This is to certify that the information provided is correct to the best of my knowledge, and I understand 1 am responsible for all charges
incurred from this application. pp
DATE 1 1) SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: �1. I OWN the property. ❑ 2. I DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
If
disposal system.
DATE SIGNATURE
DCHD (12-90)
r • . DAVIE COUNTY HEALTH. DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME _ /f�S l/"✓
ADDRESS
PROPOSED FACIILTY f` -,A a ( -�
DATE EVALUATED 2—`Z 1�
PROPERTY SIZE �'4C
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4
Landscape position
L L
Slope %
—
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
77
Structure
X 5-J 4 -
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: �--5
LONG-TERM ACCEPTANCE RATE: /
REMARKS:
DCHD(01-901
EVALUATED BY:�
OTHER(S) PRESENT:
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 fine 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
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/fu
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