300 Lutz Ln (2)Perrnittee's DAVIE COUNTY HEALTH DEPARTMENT
,-.-emy/jr- Environmental Health Section PROPERTY INFORMATION
! �1C� �� P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION "
AUTHORIZATION NO: 002707 A Road Name:30D Lo Z GAZip: 2 t r.
**NOTE** This Authorization for Wastewater System Construction MUST 13E 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 Permits.
(In compliance with Articlf I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
% �' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
-E-•NVIR N HAL H SPECIALIST DA E ISS�JED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS_ # BATHS _2-- # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT ^� # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ✓,� ROCK DEPTH 2 LINEAR FT.
OTHER 7 CASTCJ,f % yj t.UN '~'"'Ar4 s
REQUIRED SITE MODIFICATIONS/CONDITIONS: ' `� �" �TM 1=-1:- Lk IcS OymT oF Q A:lCZOA Y
1
IMPRO EMENT PERMIT LAYOUT
As stated in�tSmsNC�C 18A.1969(5
c;o be used
.accepted SV.
MAtaahu
to
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 PERMIT
SYSTEM INSTALLED BY: '`&,zq ME
C
iT
_LP
1�1
i
I zs �-
AUTHORIZATION NO.. OPERATION PE BY:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT E SYSTEM DE IBED ABOVE HAS BEEN I
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVENPERIOD OF TIME.
DClloazrortRevrsea,:57V
) 2-17-5 It &
COMPLIANCE
CBE TAKEN AS A
Permit ke's DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property:t 1� ,r�r, # Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002707 A Road Name:.S 0 L.•LY1 , tJZi
**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 Permits.
(In compliance with Article"l I of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t -«►. fv'^ �. .- U �h,^ IS VALID FOR A PERIOD OF FIVE YEARS.
',- ENVl; f ItN A EAL H SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 1'k) KC # BEDROOMS ,, _ # BATHS _,�_ # OCCUPANTS -/� - GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
i27�1 c�
LOT SIZE TYPE WATER SUPPLY I"`II^-L-�^ DESIGN WASTEWATER FLOW (GPD)-"-kPO NEW SITE REPAIR SITE ✓�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH M- ' ROCK DEPTH 12,"
LINEAR FT. ��00
l r• : l�. a1J`> cxX< . k''tr. LL1, X 5
�., Ar :�aA Y
REQUIRED SITE MODIFICATIONS/CONDITIONS: C
IMPRO EMENT PERMIT LAYOUT
11V
i ptl�:nluu
r,
11 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. 1
OPERATION PERMIT I
SYSTEM INSTALLED BY:
C
e
T J c9
a
AUTHORIZATION NO. 27077 OPERATION PE BY:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT E SYSTEM DE IBED ABOVE HAS.BEEN INS D COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN A E TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OM (Revised) ML7 l 1 � ?�NUoiCe #1V .5 ?V/
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
1 APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME k)AV,) L- [-,)r2- PHONE NUMBER
ADDRESS SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS -3 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY w L=ZS SPECIFY PROBLEM OCCURRING '-�C-406 7A "Je
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges Incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193 �,
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APPLICANT INFORMATION
Water Supply:
Evaluation By:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
PROPERTY INFORMATION
On -Site Well Community
Auger Boring / Pit
////(4/_/�
Public
Cut
FACTORS
1 .2 3 4 5 6 7
Landscape position
�.
Slope %
2.
HORIZON I DEPTH
Texture group,1
Consistence
S
Structure
itt
Mineralogy
HORIZON II DEPTH
- Z
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
2
Texture groupr
Consistence
Structure '
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
r
Structure
Mineralogy
SOIL WETNESS
«—
RESTRICTIVE HORIZON
SAPROLITE
._
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE .
'Z
-..1
SITE CLASSIFICATION: � � ' EVALUATION BY: V
i
LONG-TERM ACCEPTANCE RATE ! OTHER(S) PRESENT.
REMARKS S�t� �O — tip-.t�
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
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
aStructure
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
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 -tern acceptance rate - gal/day/ft2 DCHD 05105 (Revised)
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