2137 Milling RdPermittee's`M`` DAVIE COUNTY HEALTH DEPARTMENT
Name:' "? -�? `"�����`'i Environmental Health Section PROPERTY INFORMATION
� {fit 4 I � � /- 1�� P.O. Box 848
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Directions to property: `"` "�-� Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
WASTEWATFR
CV.CTFM CnNCTRIICTInN Tax Office PIN:# -
AUTHORIZATION NO: 0027-05 A
Lot:
Road Name:. r•-� '>~ 2IP
1
**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.
(n compliance ance with Article 11 of G,S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
' 1 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALH) FOR A PERIOD OF FIVE YEARS.
ENVIRONNIENIAL- EAliTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE ' �I# BEDROOMS # BATHS % # OCCUPANTS - -- GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE
# PEOPLE
# PEOPLE/SHIFT
# SEATS INDUSTRIAL WASTE: Yes or No
1
LOT SIZE TYPE WATER SUPPLY/'
DESIGN WASTEWATER FLOW (GPD)
``�t NEW SITE REPAIR SITE
17 , I I {
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK
GAL. TRENCH WIDTH
ROCK DEPTH 1I +`� LINEAR FT. '�
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REQUIRED SITE MODIFICATIONS/CONDITIONS:—/-\I:-,��'A, iii 1 { ^�__1) �Jl�. .,. , Eelw ::�}� NC"r- ILL
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) 751-8760.
OPERATION PERMIT
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SYSTEM INSTALLED BY:
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AUTHORIZATION NO. O ?,? a) OPERATION PERMIT BY: 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.
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Permittees r DAME COUNTY HEALTH DEPARTMENT
Names' 1 ~� I�i-Lof-%�`%'vf� Environmental Health Section PROPERTY INFORMATION
^ , ' F P.O. Box 848
Directions toproperty: 't 'N 1 Lt) t~`j
Mocksville NC 27028 SubdivisionName:
Phone #: 336-751-8760
Section:_
AUTHORIZATION FOR
IVA4TEWATFR
Lot:
SYSTEM CONSTRUCTION Tax Office PIN:# - -
AUTHORIZATION NO: 002795 A Road Name �3 `y)Zip
**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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
! r^-• **NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
_ IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL SPECIALI5f DATE 1SSPE6
r7
RESIDENTIAL SPECIFICATION: BUILDING TYPE U_� ��� 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 �'U' DESIGN WASTEWATER FLOW (GPD) �"�f ? NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER l _1:^ L +SLI CS t ' , %T� IJ� �j� l (�h•�'�
REQUIRED SITE MODIFICATIONS/CONDITIONS:. " `���"J'�� .I .� �r��1 _ t ��L/A t� v 1 ��t� ILL t t2t,�P`
11
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) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. I) 2 1 OPERATION PERMIT BY: ��� DATE: Z
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
��/�/� APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
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NAME �� �' �t
i!/ � 0#1, n PHONE NUMBER
ADDRESS 7'131 /� li I(Iha I(.(( - /!" M.A',U'l e- SUBDIVISION NAME
DIRECTIONS TO
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LOT #
DATE SYSTEM INSTALLED �� NAME SYSTEM INSTALLED UNDER X11;'fm raSI& -
TYPE FACILITY WM NUMBER BEDROOMS NUMBER PEOPLE SERVED
n
TYPE WATER SUPPLY 0a 1 SPECIFY PROBLEM OCCURRING I1 nie- l atAIC--k "k&
V942- �LAi/ 11Ni
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of m knowledge, and that 1/nderstand I em responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGE�.N
Rev. 1193
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring /� Pit
PROPERTY INFORMATION
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Public
Cut
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: 1 Z
OTHER(S) PRESENT:
LEGEND
Landscape Potion
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
3'et
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
SC - Single grain M - Massive CR - Crumb GR - Granular ABK -Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineral=
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 05/05 (Revised)
Landscape position
HORIZON I DEPTH
Consistence
NO 04"
HORIZON 11 DEPTH
Texture group
Consistence
HORIZON III DEPTTexture
Texture group
Consistence
HORIZON IV DEPTH
group___
Consistence
r�zr���s�����■���
Mineralogy
SOIL WETNESS
SAPROLITE
CLASSIFICATION
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: 1 Z
OTHER(S) PRESENT:
LEGEND
Landscape Potion
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
3'et
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
SC - Single grain M - Massive CR - Crumb GR - Granular ABK -Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineral=
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 05/05 (Revised)
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