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Davie County Health Department
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ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27029
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.***
AUTHORIZATION NUMBER
NAME ri( u'!(y1r�/`7 DATE �'- N127) 1
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION/�,yr°r �r�'��/ir.�� CII/ l%'u C r%rJy ? / T V
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICE*** THIS AUTHORIZATION FO ,1 5 EWATER SYSTEM CONSTRUCTION I5 VALID FOR A PERIOD OF FIVE (5) YEARS.
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ENVIRONMENTAL WATH SPECIALIST DATE
DCHD 10/95
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**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)
NAMEC CPROPERTY ADDRESS
LOCATION . I // rl/_ /91 P/,.%/t ,%7 e`<"/J / .I LJ,r// r ,° A- � ra
DATE
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS ' # BATHS p� # OCCUPANTS �, GARBAGE DISPOSAL: YesV
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE fI/' TYPE WATER SUPPLY f DESIGN WASTEWATER FLOW (GPD) NEW SITE f�-REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/i GAL. PUMP TAW GAL. TRENCH WIDTH..?C ROCK DEPTH LINEAR FT._c�'t%l
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BY
**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 l/U
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v
AUTHORIZATION NO. ��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.
DCHD 10/95
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DAVIE COUNTY HEALTH DEPARTMENT t .
--� ' IMPROVEMENT PERMIT and OPERATION PERMIT i
IMPROVEMENT PERMITi
**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 it of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME PROPERTY ADDRESS !'i/,( �D %� `" 1 DATE
LOCATION r'l „f0 ;ii 1/%if ' , , <"� ,� /t ,✓ -1
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE r i / # BEDROOMS. # BATHS V t OCCUPANTS /GARBAGE -DISPOSAL: Yes o
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE aril TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) _ / NEW SITE i_.--' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/"',-,? SAL. PUMP TANK GAL. TRENCH WIDTH '',c' ROCK DEPTH LINEAR FT. r
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT PERMIT BYi?�
**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 l/►��„�,;�/(�.
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r7B
AUTHORIZATION NO. 0/6—/ OPERATION PERMIT BY �C!+ i 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.
i
DOHD 10/95
WOW
AM
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED�����
ADDRESS
PROPOSED FACIILTY
PROPERTY SIZE 49.0-G
LOCATION OF SITE =7Z&5Ze_-V
Water Supply: On -Site Well _ Community Public [�
Evaluation By: Auger Boring i/ Pit Cut
FACTORS
1 2 3 4
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
ov
Texture group'
Consistence
/
Structure
�C
Mineralogy(
y
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
J
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY:i'/
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT
REMARKS:
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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V=, -.-y 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
3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Anirular 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 (01-901
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
JAN 2 4 1996
1. Application/Permit Requested By
Mailing Address To 7Ardue,—lU6 p Home Phone 2607
&AIAImC& _( L, 2!7D0L Business Phone 716 700-7957
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve
❑ Business
❑ General Evaluation & eptic Tank Installation Permit
❑ House 9 Mobile Home
❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms 19—
Dwelling Dimensions 6
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers �1 Water Usage Figures _
7. Type of water supply: ST Public ro �Ij on Of ❑ Private
8. Property Dimensions a -c -;u Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Yes
❑ Basement/Plumbing
❑ Basement/No Plumbing
04ashing Machine
1I?'5ishwasher
❑ Garbage Disposal
VIN"o
❑ Community
'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
G�/JS
ow AJaVey (i�GUCAore9 �f?J
,6 PS! /C' 51/0 d `C_5- lh' a Kke c :t.e. , & &
a�oNf iv/i-es fuz� LeF�-
/,I4), pard o e /0410 Coo Oe h;&4 14as-e—
Gil Gr�e�.J Tiurn , f'rc per �v w l ( b e
51 a C- o r re t-1 C- I �a n C o
This is to certify that the information provided is correct to the best of
incurred from thispli at'on.M
DAIE
Tax Office PIN: # 5�(4/-0 -00(07
,E? poo GD 0c)PROPERTI/ ADDRESS, as follows:
Road Name:
City: 11e1t1,qyre- Jj . G
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
knowledge, and I understand I am responsible for all charges
IGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1:11. 1 OWN the property. M2. I DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie Count galth Department to enter upon abpve described
property located in Davie County and owned by S L( V. A ,1 �-C, =e ti Cl a1q- �1
to conduct all testing procedures as necessary to determine s ' site's suitability for a ground absorption sewage treatment
and disposal, system.
1.2
l (0
DATE SIGNATURE
DCHD (1/93)
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