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1425 Milling RdPhone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: &W, , ' ` �r\ Phone Number .>�'- L,- Lk g L,- U Kb (Home) Mailing Address: ML\ \ =�� K� \ (Work) Ve j (2: VW Email Address: Detailed Directions To Site: A/O ' r mC; fij � � � kr •v h`- eff � � % �t � � Cab ►4 � 1, �,�•�-�.�-��4�,�-yeti , �.��-- cc�ss�n�, Cc��I< ,_, ;-,1� b�. 3 ' �� .�J Property Address; lk A -),C. 9 - Please Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Number Of Bedrooms:__�/ -Number Of People: Is The Facility Currently Vacant? Yes v'' If Yes, For How Long? Any Known Problems? Yes (S)If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: e A GCX e Number Of Bedrooms:1J)J4 Number of People 42 Pool Size: A) ,it Garage Size: At •. Other: Requested By: (j �� Date Requested: (Signa e) For Environmental Health Office Use Only Approv d Disapproved Comments: -G/;, L�/1/(� -awl Environmental Health Specialist Date: 'f *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Paid By: Received By:_ Account #: Invoice #: Date: Davie County Health Department •p 1836 ' Environmental Health Section R P.O. Box 848 210 Hospital Street !� p Courier # : 09-40-06 U Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: &W, , ' ` �r\ Phone Number .>�'- L,- Lk g L,- U Kb (Home) Mailing Address: ML\ \ =�� K� \ (Work) Ve j (2: VW Email Address: Detailed Directions To Site: A/O ' r mC; fij � � � kr •v h`- eff � � % �t � � Cab ►4 � 1, �,�•�-�.�-��4�,�-yeti , �.��-- cc�ss�n�, Cc��I< ,_, ;-,1� b�. 3 ' �� .�J Property Address; lk A -),C. 9 - Please Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Number Of Bedrooms:__�/ -Number Of People: Is The Facility Currently Vacant? Yes v'' If Yes, For How Long? Any Known Problems? Yes (S)If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: e A GCX e Number Of Bedrooms:1J)J4 Number of People 42 Pool Size: A) ,it Garage Size: At •. Other: Requested By: (j �� Date Requested: (Signa e) For Environmental Health Office Use Only Approv d Disapproved Comments: -G/;, L�/1/(� -awl Environmental Health Specialist Date: 'f *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Paid By: Received By:_ Account #: Invoice #: Date: yI� 55'19 of. CO W �4 CO CO845" , i V - ' 60 ---.�� 200 __. . " Lsa o � 1425 � ....._ r j 3394 � 5392 8268 424 ' 1 d� (< 250 +, .6 1.380A '�� 9109 �sz1 06 4260 ©� 1` OV azo 1.945A 0166�+J 1.504A +3t nnn a tn!` (X o aYf� All data is provided as is without warranty or guarantee of any kind either expressed or implied Including but not limited to the implied w( warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of " Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out Pri nted: J u n 16, 2014 of the use or inability to use the GIS data provided by this website. Pennittee's t: �,vi DAVIE COUNTY HEALTH DEPARTMENT �! X959-- r �` Environmental Health Section PROPERTY INFORMATION Directions to property: k ,"s' P.O. Box 848 Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION AJJ 1 i AUTHORIZATION NO: 002651 A Road Name: Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any,Bwlding Pemlits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when_appiying for Ruildi iz Permits. (In compliance wi[h-Articl^ 11 of G.S. Chapt&,j30A1 Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) " t ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � ,-- IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRON1vIPTALAL/TH5PECIALIST� DAT IS UED RESIDENTIAL SPECIFICA`TII.ON: BUILDING TYPE l..a��l H# BEDROOMS ! # BATHS ;2- # OCCUPANTS _9 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No TYPE t -.» WASTEWATER LOT SIZE WATER SUPPLY DESIGN FLOW (GPD)rr"'� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH'^1� ROCK DEPTH LINEAR FT. �' `� ` ; ► �,i � �l 3 p.�. �,`-�"•3i„�-v�,y • � OTHER � I„<. �..- �/ ,� .�s: 1 D REQUIRED SITE MODIFICATIONS/CONDITIONS:t�" IMPROjVEMENT 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 PERMIT I11 ts SYSTEM INSTALLED BY: I �! P44 �Z$ t�D t,470 Ytw 114 GW4 r ::7�I,t 1� J2 -? AUTHORIZATION NO. OPERATION PERMIT BY: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATEA�H41'Y D SCRI$ED BOV HE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMEN SYSTEMS GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. INSTALLED IN COMPLIANCE kLL IN NO WAY BE TAKEN AS A Permittcc's Flame: 1"�`P� } t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848 l PROPERTY INFORMATION vc\�`, J } l..t,.l h- �r It,• � Directions to property: Mocksville, NC 27028 Subdivision Name: (k Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - SYSTEM CONSTRUCTION t AUTHORIZATION NO: 0 0 2 tz 5 1 A Road Name: ti 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 for-Buildittg Permits. (In compliance with -A -ClelI 1 of G.S. Chapter] 30A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ��.,, • �4-* , } i�' C �? IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEAeTHSPEN;NLIST,i DATE✓ IS UED RESIDENTIAL SPECIFICATION: BUILDING TYPE 'C-�LdM H# BEDROOMS I"1 # BATHS # OCCUPANTS L4 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No G LOT SIZE TYPE WATER SUPPLY-'�--- DESIGN WASTEWATER FLOW (GPD) C_ NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� RO/CK DEPTH LI A LINEAR FT. 2 OTHER h 11�i i^v-i r.� L;1 1 -i l_ C� 1 �7 t- r1(a f: r I� ,�f t p C'�? lT r1,►.... REQUI RED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT I;AYOUT .r .;,.l y;. 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 ►t5 SYSTEM INSTALLED BY: AUTHORIZATION NO. X111 OPERATION PERMIT BY: 7-1 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA H Y D SCRI D BOV WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMEN SYS GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 07!02 (Revised) - 17)u INSTALLED IN COMPLIANCE ILL IN NO WAY BE TAKEN AS A Permittee's- r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY, INFORMATION `0�\ P.O. Box 848 Directions to property: Iii t t'-� !` ~ Mocksville NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: AUTHORIZATION FOR WASTEWATER _ SYSTEM CONSTRUCTION Tax Office PIN:#_ AUTHORIZATION NO: 002651 A Road Name: 1 Lot: Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pen -nits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for.Building Permits. (In compliance with Article l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 1 f ) f W ti. t f ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIROPjME?NTAL HEALTH SPECIALIST DA# ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE t, -'Wt -4 hi# BEDROOMS # 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 ZGPD) -' NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE '� GAL. PUMP TANK r GAL. TRENCH WIDTH �' (,=' ROCK DEPTH Ilk LINEAR FT. i �� j L. r� .�.. 1 t C � t 1, ��'►. THER!-1 cN ,,._.. �, REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERIL ITLAYPEzf � it �c0� rl 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 rv\ l,) SYSTEM INSTALLED BY: �fJ �� 11.1 c'r�. t Y5 r— Ll �WL �`� 71,D r,4 7Q �� 1;XtSY/►ala Is r AUTHORIZATION NO. ?rte OPERATION PERMIT BY: D j "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICAT��IIAT I Y E 1SCRIBED BOV HA E INSTALLED INC MPLIANCE WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMEN SYSTE S", HALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: Billed To: Reference Name: Proposed Facility: Property Size: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit PROPERTY INFORMATION Tax PIN/EH #: Subdivision Info: Location/Address: Date Evaluated Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % 440 HORIZON I DEPTH -Z Texture group Consistence Structure Mineralogy- HORIZON II 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 p SITE CLASSIFICATION: e LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: 0 : 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 F1- Firm VFI - Very firm 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/ft2 DCHD 05/99 (Revised) CC =C.......:::::::::::::::::::::::::::::::::::::::::::::��:::: .... �: : E=:::E::::::E:::::::::68:�:::::::::::::::9:6::::::6:E::::: _.. .......................................................... a � ..........................................................� .............. .......................................... 9. . �..................... .................................... ::: ': �CC::::::::::::::::::�:::;'::::::::::::::::::::::::::':::: ■..�C.�■........................i=..........................5.... :'::C�C::::::::::::CC:C::::::C:::CCC::C:::::::::::::::::::::�:::: .�■.. �...........................�.............................. .. .......................................................... � �C■.■.............■............................................ � ��.:::::::::::::C::::::::::::�i:C::::::C::::::::::::C:::::CC:: � ��CC':::C:'::::::::::::::::::C:C::::::::::C:::::::::::::::�:: �...C.....0............ ..................................... 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P NAM DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) ;S PHONE NUMBER ��-Ss'I► Z ADDRESS 1 `[ ZS' SUBDIVISION NAME L LOT # DIRECTIONS TO SIT ?k . CA— 0111,Ui iW - -f jbT - C/% -d s1 c6u66 an [-4 s. 4., iac-,ast err--4-11�r DATE SYSTEM INSTALLED q 7 NAME SYSTEM INSTALLED UNDER Y 10An tni,i S TYPE FACILITY �NUMBER BEDROOMS 4 NUMBER PEOPLE SERVED TYPE WATER SUPPLY welt SPECIFY PROBLEM OCCURRING' DATE REQUESTED C - Z'0 L INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowleadge, and that 1 understand I am resporyfible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT[f IDWX-f (/1t dN. _OL1% -✓W Rev. 1/93 f r • @rtg # 4 "i S �' " q q � DLL i sw"'1Y fit; � �a� � 4 q � � `b'• MY +� c � '.� �' � p r r�. 'p. ' *'16�� ' r i , e, r