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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