503 Mr Henry RdAUTHORIZATION NO: r 10' � � DAVIE COUNTY HEALTH DEPARTMENT
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Environmental Health Section
Permiftee's-.� "�j ? P.O. Box 848
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PROPERTY INFORMATION
Name: L I~f� N L l r��.i Mocksville, NC 27028 Subdivision Name:
Phone #: 704-634-8760
Directions to property: 'r-' i� �� �N U4G Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
L-a-fyo i`ykC-,oiv Road Name: Zip: 7 7r 1-1
**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.
(In compliance. yvith Article It of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
tI " Iq7 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIR N t: HEALTH SPE IAi.IST DATE SUED
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS
Permittee s
Name:yw
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Directions to property: L= -�:' i�`•w 0!,`r4
PROPERTY INFORMATION
Subdivision Name:
Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# —717
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Road Name: w i- ! _ `�" Zip. ,'f Ci
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH'SPE IIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS _�-) # BATHS = # OCCUPANTS t GARBAGE DISPOSAL: Yes o(S)
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE;? •s" eTYPE WATER SUPPLYDESIGN WASTEWATER FLOW (GPD) �t� NEW SITE ` REPAIR SITE
'1 ! 7 " �� /
SYSTEM SPECIFICATIONS: TANK SIZE � � GAL. PUMP TANK GAL. TRENCH WIDTH ✓ ROCK DEPTH 1 �' LINEAR FT:-��•�
OTHER ' c I d'-fkLi r, -)i) T 10 t3 1>071%
REQUIRED SITE MODIFICATIONS/CONDITIONS: yL\i t -y, 51
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14661 LL
IMPROVEMENT PERMIT LAYOUT
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"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: i.0 N 1 T'a; 0-
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AUTHORIZATION NO. 'Q OPERATION PERMIT BY: DATE: /
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO S 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 05/96 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE R n 2
Davie County Health Department V L�
Environmental Health Section OCT
P.O. Box 848 X997
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed L)En� �A N -T 2QRCP---F:S Contact Person
Mailing Address (2 lest o0 1R'-�A Home Phone
City/State/Zip HCX-v-'SV1 6(C -'D-70Z-3 Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [Site Evaluation
City/State/Zip
[ ] Improvement Permit & ATC [YJ Both
4. System to Serve: [ ] House N#f Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People --J— # Bedrooms # Bathrooms_ k/ Dishwasher [ ] Garbage Disposal
[]°Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [ ] County/City [- JVell [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ ] No
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT **fQVV DM OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: o2 - WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # J�7 %- ��_ - /15 a� �0 6 �GP,V' (e Ltc, AAl--,/ni�nn(l �r0
Property Address: Road I�1ame N% I` . gt-wP,Y S ROA6 fit. D 'tp� ��� D6CXBttY (l �cTrc,H Ln
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City/Zip 1J6 6L.W Z1e ;
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If in Subdivision provide information, as follows: 3
Name: ;
Section: Lot #:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Represen�tattivee of the Davie Cou%ty `Health Depart t enXron above described property located in Davie County and owned
by �7/l 1! / tvJ v� 7Y �, NJZfJt°J1�2 h �' to co� uctes
tinp rocedures as necessary to determine the site suitability.
DATED IT f g74-
J SIGNATURE ,.(/J o � l
Revised DCHD (06-96)
THIS AREA MAY BE USED rOR DRAWING YOUR SITE PLAN:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME 1,QA�i ���'� DATE EVALUATED
PROPOSED FACILITY .MSG PROPERTY SIZE
SUBDIVISION ROAD NAME
Water Supply: On -Site Well j Community Public
Evaluation By: Auger Boring ✓/ Pit Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
L
Slope %
Z29,
HORIZON I DEPTH
— /D
Texture groupL--
L
1.
Consistence
Structure
Mineralogy
1;
HORIZON II DEPTH
f p —
_ Z
Texture group
C
G
Consistence
Structure
hj
Mineralogy
HORIZON III DEPTH
Texture group
Sn
Consistence
;
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
p.
SITE CLASSIFICATION: VS
0
LONG-TERM ACCEPTANCE RA'
REMARKS:
Landscaue Position
LEGEND
EVALUATION BY:�-T
OTHER(S) PRESENT:
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 (01-90)
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