152 Loop St � .
. �
' " DAVIE GOUNTY HEALTH DEPARTMENT
.�..-� � Environmental Health Section a,
� P.O.Boa 848/210 Hospital Street l !�Q �
� Mocksville,NC 27028 �5� V" �
(336)751-8760
Account #: 990003730 Tax PIN/EH#: 5745-16-2749
Billed To: Larry Daniel . Subdivision Info: j��tl�' S/���� c'o.N�er� L��P s�
Reference Name: LocatioNAddress: 9�6-Barriet-Read-27028
Proposed Facility Welding shop Property Size: see map
ATC Number: 4197
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental.
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUC ON IS VALID FOR A PERIOD OF F VE ARS.
, ' � / r _
Envuonmental Health Speciahst s Signature: � / Date:
� CERTIFICATE OF COMPLETION ►
� **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
, 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.
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Septic System Installed By: � � -� �`''�'
Environmental Health Specialist's Signature: °� Date: .; ��
DCHD OS/99(Revised)
F, i , _ , � • ° ' ' DAVIE COUNTY HEALTH DEPARTMENf S,�( �
, • Environmental Heaith Section � bQ �
P.O.Boa 848/210 Hospital Street / U �
Mocksville,NC 27028 � �j�
(336)751-8760
Account #: 990003730 Tax PIN/EH#: 5745-16-2749 /
Billed To: Larry Daniel Subdivision Info: �{�I/c� ����� C4�j✓�Li'� G�d�s�
Reference Name: Location/Address: 9b6-BanieH�ead-27028
Proposed Facility Welding shop Property Size: see map
ATC Number: 4197
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUC ON IS VALID FOR A PERIOD OF F VE ARS.
' � / �
Environmental Health Specialist s Signature: i'� Y� / Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
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S tic S stem Installed B : �/ •' � "'�
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Environmental Health Specialist's Signature: / � Date: ��
DCHD OS/99(Revised)
, ' DAVIE COUNTY HEALTH DEPARTMENT �
• Environmental Health Section �
' ��' %�, � ' ' . P.O.Boa 848/210 Hospital Street
, ', Mocksville,NC 27028 I � �f� ��
(336)751-87G0 �
IMPROVEMENT/OPERATION PERMIT
Account #: 990003730 Tax PIN/EH#: 5745-16-2749
Billed To: Larry Daniel Subdivision Info: �j,(/(' �Q j.;s
Reference Name: Location/Address: Q��^a^�pi R�a�-27028
Proposed Facility Welding shop Property Size: see map
ATC Number: 4197
**NOTE**"This ImprovementlOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AITTHORIZATION 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). TffiS
PERNIIT IS'SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CAANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential�pecification: Building"Type #People #Bedrooms #Baths
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing:❑ Basement/No Plumbing:❑ �
Commercial Specification: Facility Type� #Peopl � #People/Shift� #Seats Industrial Waste:0
Lot S'ize "Type Water Supply�j� Design Wastewater Flow(GPD) �� Site: Nevw� Repair❑
System Specifications: Tank Siz��(�GAL. Pump Tank GAL. Trench Widt}�.����tock Depth�Linear Ftf��
Other:
accept�d Systems may al sp�be used
Required Site Modifirations/Conditions:
IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspectian ofthis
system l�etween 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.****
�
�
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Environmental Health Specialist's Signature: Date: � �S
DCHD OS/99(Revised)
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' �� �PPU ON FOR SITE EVALUATION/IhtE'ROVEM1IENT PERh11T&ATC
� . , i� Davie County Heaith Department
� S E P '� 7 2005 Environmenta/Hea/t/�Section
P.O. Box 848/210 Hospital Street
i 1 Mocksville, NC 27028
ENVIRONMEMALNEAIJN , (336)751-8760 �
DAVIE COUNiY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.• Namo to be Billed ���r� �• 1/Gd� � e' ( Contact Peraon L a�r�l �. p�1h� � �
q �� ��an� �\ R � 33�I �.g�t - 28 0� �.��,�
Mailing Addrese o G Home Phone
City/State/ZIP 1`�O LttS v� �{��, . �•L' 2�-OZ� Susiness Phona � � " �� " '���
2. Name on Permit/ATC if Diffarent than Above
��l�M� �
Mailing Addreas �JG�'Me City/Stata/Zip ����
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC �noth
4. syatem to service: � House � Mobila Homa �Business ❑ Industxy ❑ Other
5. Type system requeated: �Conventional ❑ conventional modified ❑ innovative fJac�epted
6. If 3tesidence: # People # Beclrooms � Bathrooms
ODinhwasher ❑Oarbage Diaposal ❑Washing Machino ❑easement/Plua�ing ❑Dasement/No Plumbing
7. Z£ Husinesa/Industry /Other: vorify typeWC �`� O�.1 # People �-'Or.7 �F Sinka _�
# Commodes_ J� # Showera � # Urinals' � N Watcr Coolera ,
IF FOODSERVICE: #� Seata Estimated Water Usage (gaiions per day) �� G�• ��
8. Type oE water supply: ❑ County/City I�Well ❑ COmmunity
9. no you anticipaEe additiona or expnnsions of the facility tl�is system is intended to scrve? �Yes 6�No
If ycs,iti�l�at typc?
***1111PORTi1NT'�**CLILNTS MUST COMPLETE TH� RLQUIRL•D PROPGRTY INrORMATION R�:QUEST[:D
I3ELOW. �ithcr a PLAT or S1TC PLAN hfUST BESUI31�fIT7'ED by ti�c clicnt �v[ti�TFIIS APPLICATION.
Property Diu�cnsions: 23tof x>`&'x2�$ X��2" ,.b�3 �,�VRITG DIRGCTIONS(fron�Nlocicsvillc)to PROPGR'fY:`
T�Xorr��2�iN: � S�'�'S -�b' 2.�-�Iq ��, �o I 5 0� �v C� rec�5� Lot'h�v�
Property Address: Road Name 1V•L� $�� S �-O�S�, �� C-'� �3 01 J o��
c�tyiz;n Goble�e.we.� ,�•G. �,�o � 5'r� p r��pGt �� i�. be�-�e e v�
. z�a�� ,
ITin a Subdivision provide inforruation,as follotivs: ��'�� ��'• ' ,� s � be�iO��. �ob1�.�+fh'@'L.
Namc: G�'�� ���w�;-�-� ah ��•�. Le-�-�.
Section: Blockc Lot: Datc home corners llagged: $ D
'I'his Is to ccrtify that tlie information provided is correct to thc best of iny knowlcdgc. I unda•st�nd that any permil(s)
issued l�creafter are subject to suspensioii or revocation,if the site plans or intended use clia�ige,or if ilie information�
submitted in tl�is applicatiou is fnlsi�ed or clianged. I,also,«�rdersla�rd that I nm respoi�siGle fo�•nl[cltnrges iacttrrerl jran
tlris npplicalion. I,l�crcby,givc consent to tl�c Autl�orized Rcprescntativc of the Davic County IIcallh Dc�lrhnent
to enter upon above describcd property located in Davie County anJ o�vncd by�I. Af r . 0. � '�. �
to conduct all testing proccdm•es as necessary to deternunc the site suitability �
DAT� � I 5I � s SIGNATUIt� 2
THIS AR�A MAY B�US�D TOR DRAWING YOUR SITE PLAN(In lu all f tltc follo�ving: �xisting 1nd proposcd
property lines and dimensions, structures, setbacks, and septic locations . �
�✓`�"` Sitc Rcvisit Chargc
���_ D1tc(s):
. ��,�- yo-- �8-a � �"
Clicnt NotiCcation Datc:
.
�IiS:
Sign givcn . � Account No. � �`�.�D
_ , \ �
Rcviscd DCHD(OS/03 Invoicc No. �a"5 �. :
_.,... -
r
� - " . ' DAVIE COUNTY HEALTH DEPARTMENT
. , . ..
, ; � " '' . Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003730 Tax PIN/EH#: 5745-16-2749
Billed To: Larry Daniel Subdivision Info:
Reference Name: Location/Address: 956 Daniel Road-27028
Pro'osed Facility: Welding sho' Pro'erty Size: see map Date Evaluated: ��
Water Supply: On-Site Well - Community Public
Evaluation By: Auger Boring Pit Cut ��
FACTORS 1 2 3 4 5 6 7
Landsca e sition L�
Slo %
HORIZON I DEPTH �� �!
Texture rou
Consistence 1/'
Structure �- �
Mineralo � / _
HORIZON II DEPTH � =' `
Texture rou
Consistence � '
Structure � f
Mineralo
HORIZON III DEPTH
Texture rou
Consistence `
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION '
LONG-TERM ACCEPTANCE RATE r
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 1 OT ER(S)PRESENT:
! f '
� REMARKS: � 5
LE ND
T.andscape Position
R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope , N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope
�Tg � -
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 '
.ON I4T ,N . ,
�15� •
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�€t ; .,
• NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic -
&tl.ustutg _ �
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloQv
1:1,2:1,Mixed
LY�t�S •
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-gaUday/ft2 , DCHD OS/OS(Revised)
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