1451 Milling Rd (2)Permittee's,f` % DAME COUNTY HEALTH DEPARTMENT 1 /�
Name: `fir '� ''� ==t`�' ` . r �'�%::!" Environmental Health Section PROPERTY INFORM v
P.O. Box 848
Directions to property: r t- .%} a' f ` Mocksville, NC 27028 Subdivision Name:
t Phone #: 336-751-8760
✓r �'r c. t' r ;''. !`�� Section:
AUTHORIZATION NO: 002"M5 A
Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION ll16-1 A11t'W
Road Name: ✓ ,Cf�p: Q7i�
**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 I 1 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.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE�� # 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 ---� r6ESIGN WASTEWATER FLOW (GPD) 6 ? if NEW SITE REPAIR SITE - L111-
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHL?(, ROCK DEPTH LINEAR Fr 9 �•.5
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
s
k
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:
64 4
E :
AUTHORIZATION NO. C'. • OPERATION PERMIT BY: % / f DATE:
**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)
41
Permictee= ; .' i� �DAVIE COUNTY HEALTH DEPARTMENT y
Name: ` Environmental Health Section PROPERTY INFORM�•I�10
P.O. Box 848 I
Directions _tii`propeity:,., i hlocksville, NC 17028 Subdivision Name:
Phone #: 336-751-8760
�'�' • '"
AUTHORIZATION FOR Section: Lot:
WASTEWATER Tax Office PIN:# M
SYSTEM CONSTRUCTION-
- ^ AUTHORIZATION NO: 0 0 2 5 A Road Name: 9 %�' f1(r Vr �(p; 210&
**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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
f ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t rX ' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE _4 # BEDROOMS # BATHS ? # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT f # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY,_ [F /)SIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH t_ 1 ROCK DEPTH ,, /) LINEAR FT. .
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: "
IMPROVEMENT PERMIT LAYOUT
f
s
k�
i
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 f
Ij SYSTEM INSTALLED BY:
`#tel
.1 1(
AUTHORIZATION NO OPERATION PERMIT BY: / i' DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 07/02 (Revised) — —
APPLICANT INFORMATION
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
Community
PROPERTY INFORMATION
Public
Evaluation By: Auger Boring • Pit 1/ Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
MincralogX
HORIZON II DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON III DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON IV DEPTH
Texture group
Consistence
Structure
MineralogX
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: I OTHER(S) PRESENT:
REMARKS: ate`
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 firm EFI - Extremely firm
.w
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VI3 - Very plastic
' r ct re
'SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prisipatic
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
DCHP 05/99 (Revised)
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NAME
ADD9&z r /
DIRECTIOy,�TO SITE
SS�',(A
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICAT ON FOR IMPROVEMENT PERMIT (REPAIR)
f f PHONE NUMBER '✓/ `
G� SUBDIVISION NAME
LOT #
'e)7"r "� 0 Ko//
I,
DATE SYSTEM INSTALLED i NAME SYSTEM INSTALLED UNDER Zzet2 /J'i`.o
TYPE FACILITY W7 NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY ��,_,�"SPECIFY PROBLEM OCCURRING
� r
DATE REQUESTE INFORMATION TAKEN BY�I�/
This is to certify that the information provided is correct to the best of my knowledge, and a n e stand a aspon I for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193