2464 Milling RdPen nil 1l ! DAVIEICOUNTY+HEALTHIDEPARTMENT
Hamer-'EnvironmenlaliHealth Section PROPERTY INFORMATI
DHead o_ns roproperty:-1-JCI. 7!!]._it't )LLIn�(a Moak OIIIaNCyx702R SubdrvitiiomName, 1'� 1�(
--A)R.9-_-- Phan # 33fi-75I 8760
SLCIIOn: - Lot:
- ' n1UTHORI%ATION.FOR - -
_WASTEWATER Tax'OtlicF'.PINik.
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Section 1900 Scwage3Treaufieoi and DisposalSy.stems)
RESIDENTIAL SPECIFICATIONi'BUILDINGSY PE' TM BEUROOMSL�3—aNnTHS 7 pOCCUPANTS q GARBAGE DISPOSAL:.Yes or No
COMMERCIAL SPECIFICATION , FACILITY.TYPE
V - #PEOPLE_ ppEOpLFJSHIFf p SEATS'TE:,Y
_ INDUSTRIAL WASu a, Na
LOT SIZE TYPE WATER SUPPLYiDESIGN WASTEWATER FLOW(GPD) �O,NEW SITE -,RE -PAIR SITE
_-
'SYSTEM SPECIFlCATIONS: TXNK SIZE GAL PUMPT2ANFKr --CAL« TRENCH WIDTH iROCK DEPTH IZ LINEARFT.
'OTHER==�T4Qn1'w IIpJ (�/f.5 �I �/ _,�h.__rn
REQUIRED SITE MODIFICATIONSICONDITIONS:�AI-\II-ILi &A] (.%i �-IWE i ; LL'r JV, 17kUt ( aL
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FOR FlNAL INSPECTION OFTHf$ SVSTLWI PI,EA52(`AEL WE:
.8 -TLI EPHONG a IS p36) ]Sf 9]60.
'OPERATION PERMIT - -
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**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 11,617 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.'''j'_.!
ENVIR NMENTAI HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE - . t_ + # BEDROOMS _ # BATHS 71 # OCCUPANTS+_ GARBAd DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE - TYPE WATER SUPPLY iQV Y DESIGN WASTEWATER FLOW (GPD) C� NEW SITE i REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH .�1r ROCK DEPTH, " LINEAR FT��
C , .
OTHER - ". %` I t� Ti;.J j r' `�'p.rt; �✓ `\
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPECTION OF THIs-SYSTEM"PLEASE`eALE nTWEEN 8:30 `9:36 A.M. ON THF�DAY OFJNS't'ALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
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AUTHORIZATION NO.0026 0 OPERATION PERMIT BY: ��' L DATE: Z/-2
T.& &, /J. l/r
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA 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 02/02 (Revised)
Perini s� `"' "'
DAVIE COUNTY HEALTH DEPARTMENT
-Name: ' (t� l.. .+'*JQ 1 t_
Lc 1,
Environmental Health Section
PROPERTY INFORMATI N
P.O. Box 848
= Difecti'ons to property`
Mocksville, NC 27028
Subdivision Name:
r . ~ 'j"
l:.
Phone #: 336-751-8760
• 1" ;I := c,:
Section:
Lot:
AUTHORIZATION FOR
WASTEWATER
Tax Office PIN:#
- -
_
SYSTEM CONSTRUCTION
002'S
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`
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it f-
AUTHORIZATION NO:
Road Name..
+"y ip:
**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 11,617 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.'''j'_.!
ENVIR NMENTAI HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE - . t_ + # BEDROOMS _ # BATHS 71 # OCCUPANTS+_ GARBAd DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE - TYPE WATER SUPPLY iQV Y DESIGN WASTEWATER FLOW (GPD) C� NEW SITE i REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH .�1r ROCK DEPTH, " LINEAR FT��
C , .
OTHER - ". %` I t� Ti;.J j r' `�'p.rt; �✓ `\
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
z
FOR FINAL INSPECTION OF THIs-SYSTEM"PLEASE`eALE nTWEEN 8:30 `9:36 A.M. ON THF�DAY OFJNS't'ALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
J�
C
W 4u
F�-:otiT -
.V
Y:
} {arcic't G\ C.jdv k 6
1
1,ci �(te W(ti11) neW
_PT Cy-
i12 il�
Ll 0 %
1 ..
AUTHORIZATION NO.0026 0 OPERATION PERMIT BY: ��' L DATE: Z/-2
T.& &, /J. l/r
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA 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 02/02 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION `_`W
i APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) �J
NAME �"� PHONE NUMBER /,, 3 a 7 1
ADDRESS AN (a �� �r 90C4<3 SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER W'LLI G e 6lrao� cw
TYPE FACILITY rNUMBER BEDROOMS �- NUMBER PEOPLE SERVED 3
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �Ll �A l�✓ S
504 AuAC' wz) OF (atlur
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowl�dge, and that I understand I amresponsible all charges Incurred from this application.
n
SIGNATURE OF OWNER OR AUTHORIZED AGE
Rev. 1/93
APPLICANT INFORMATION
Account #:
Billed To:
Reference Name:
Proposed Facility:
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #:
Subdivision Info: L
Location/Address:
Property Size: Date Evaluated: �6 —Zg —CSO
Community
Evaluation By: Auger Boring ✓ Pit
Public tl/
Cut
FACTORS
1 2 3 4- 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
SOIL–
Consistence
Structure
ER
Mineralogy
HORIZON II DEPTH
1
Texture group
sc,
Consistence
r I
Structure
Mineralogyl
HORIZON III DEPTH
Texture group�-
Consistence
s
Structure
S
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: �JK lstCIMJ C� lG�/VK-�')
OTHER(S) PRESENT:SS�C
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
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)