157 Murphy Rdw�
Perrnittee's-
Name:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
<< t; P.O. Box 848
PROPERTY INFORMATION /1131U
Directions to property: Mocksville, NC 27028 Subdivision Name:
. 4!/6- i, ; F; ) Phone #: 336-751-8760
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 0029"22
ii
Section:
Lot:
Tax Office PIN:# - -
Road Name//'
**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)
***NO"l IUE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 41 # 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 ` `1 DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
i
SYSTEM SPECIFICATIONS: TANK SIZE" GL PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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.
gOPERATION PERMIT
1 1. SYSTEM INSTALLED BY:
puvngTC(4-
5hoafi
S Make
SZO'
1AUTHORIZATION NO. OPERATION PERMIT BY: %
` DATE: ✓ / �� /
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S S M DESCRIBE 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.
DCHD01/02(Revised)
Perrrirtte6 s -„,U DAVIE COUNTY HEALTH DEPARTMENT
Name: -� r Environmental Health Section
P.O. Box 848
PROPERTY INFORMATION
W31c)�
Directions to property: a ' ' ' ' ` ` ' Mocksville, NC 27028 Subdivision Name;
Phone #: 336-751-8760
1 Section:
AUTHORIZATION FOR
/ WASTEWATER
Lot:
e SYSTEM CONSTRUCTION Tax Office PIN:# - -
AUTHORIZATION NO: 0 0 2 A Road Name:, r ' `'; f I✓r ZIp f "
**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)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE I # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK '�`� GAL. TRENCH WIDTH
REQUIRED SITE MODIFICATIONS/CONDITIONS:
# SEATS INDUSTRIAL WASTE: Yes or No
NEW SITE REPAIR SITE
_ ROCK DEPTH LINEAR FT. "
JW_R0YE.MENT.EERMIT-LAY0IJ.T
i
g..� y.
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.
TION PERMIT
SYSTEM INSTALLED BY:
I .c yCV tie.5
Is
NX
J
IS C�CJC
5Zp' 40.1 a ,`
N OPERATION PERMIT BY: /��'t DATE:
1UTHORIZATIONO_
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS M DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 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.
DCHD ozroz (Revised)�!d! '�,,./ • 431 � (/ �G U 2 ,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
PROPERTY INFORMATION
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy SEW
HORIZON 11 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 5
LONG-TERM ACCEPTANCE RATE e Z
SITE CLASSIFICATION: 2�
LONG-TERM ACCEPTANCE RATE: e ZS
REMARKS:
LEGEND
EVALUATION BY: bl I ►y 11l 4 F""QQ� _
OTHER(S) PRESENT: Wvl'd(o
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
) QLq
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
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
j\jotes
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 05105 (Revised)
ADDRESS J`- /
DIRECTIONS TO S
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
%� APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) //
I�`G PHONE NUMBER llgZ- 2q
SION NAME
LOT #
-
DATE SYSTEM INSTALLED 86 NAME SYSTEM INSTALLED UNDER 6pecgrs or SSP-ee
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY Gl i SPECIFY PROBLEM OCCURRING �^
1 14dM.P 4/AAlP�/ . ,?h(PA09' �/kpd 17) clAmiP.(L?, [A9_llh�'`/ (la -W&
DATE REQUESTED INFORMATION TAKEN BY '
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
tall¢ 3-�ao9 ��"•
' 6 I �•
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) D �V
NAME OLY4erISA 1W ner PHONE NUMBER qq2-Zgglq
ADDRESS 151 M 40h� 9d SUBDIVISION NAME ALA
LOT # NIA
DIRECTIONS TO SITE bbl •�_�AiLl3 VAS3- Wad "AAF i Li MUS
DATE SYSTEM INSTALLED S NAME SYSTEM INSTALLED UNDER VJfh�(LS (��e�tO�S Oj/ll�
TYPE FACILITY JhAj �f, NUMBER BEDROOMS NUMBER PEOPLE SERVED 5
TYPE WATER SUPPLY C "-Y— SPECIFY PROBLEM OCCURRING &OtLl Ll.D i n
DA E REQUESTED `3-C1- ori INFORMATIO AKEN BY �I
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
1'6 ttS-V' S"oWJ A Ino t eaY4.
GoMaps GIS Pagel of 8
http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=35713&CFTOKEN=84491142 3/10/2009