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• Permit:ge's . � � '�� DAVIE COUNTY HEALTH DEPARTMENT
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Name: �9�"' t '� r4Y��-z'.��=�z iJf '�'--+'� �'-»� Environmental Health Section PROPERTY INFORMATION
' + P.O. Box 848
�irections to ro ert : � �''�r+ ��t �� 4=.y�j'���'��
�,_, P P Y . 1�1ocksville,NC 27028 Subdivision Name:
��; - �� '^;.,� Phone#: 336-751-8760
�",t'�.,f..,¢.��'��-�..; i�..� .• Section: Lot:
� ' AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTF,M CONSTRUCTION - �
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AUTHORIZATION NO: �'�'�;`��. A Road Name:����.° E 1 . ;i`;;} �_,Zip _ ;� �c.�:C�•
**NOT'E**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 Pennits.
(In compliance with Article 11 of G.S.Chapter 130f1,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
� ✓. �
" �r� / ,r,. ***NOTICE***THIS AUTHORI7,ATION FOR WASTEWATER CONSTRUCTION
� ..�` �',�, ( �-��_ �� �r�J I r;�r�".%"� IS VALID FOR A PERIOD OF FIVE YEARS.
�ENVIRONIy1ENTA4l-�EAL-TH SPECIALIST D�TE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE {' #BEllROOMS #BATHS ti OCCUPANTS GARBAGE DISPOSAL:Yes or No
i i G��1�I f�X
COMMERCIAL SPECIFICATION: FACILITY TYPE 5�'�t"7�#PEOPLE � #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
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[.OT SIZE TYPE WATER SUPPLY �?�"r��•f� DESIGN WASTEWATER FLOW(GPD) � ''-�-�I� NEW SITE REPAIR SITE •�.,!'`_
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SYSTEM SPECIFICATIONS: TANK SIZE (.r��GAL. PUMP TANK GAL. TRENCH WIDTH �--'t'�� ROCK DEPTH �-= LINEAR FT. ��4"�
� .—.,
OTHER � �jt��F'_,�t^� (/J-1�i.� I:�.%;�,''�..
� REQUIRED SITE MODIFICATIONS/CONDITIONS: �a�'?��f��.-�" �✓r'`� a��l'�!l�,�� � 1 �� `' � 'r'� �� p �� '� � �'�� ``' �� �
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IMPROVEMENT PERMIT LAYOUT `�
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT n � (�� ��
P�IJI.. L-- EM INSTALLED BY: �-�'1�� S "r"��I'�
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AUTHORIZATION NO. ���'"� OPERATION PERMIT B � DATE: � �
•+THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS SCRIBED ABOVE HA E 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.
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�Rer�nitte�s :; �, �� , ' `DAVIE COUNTY HEALTH DEPARTMENT
M Naine; ~ � �` � n �~���l •� ' ;�:-s t' ,� Environmental Health Section PROPERTY II�iFORMATION
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t P.O. Box 848
�Directions to ro ert : E�''�� i� ; �,-ts`\i�,�F
, , P P Y , hlocksville,NC 27028 Subdivision Name:
� �9 f.��'.; ��^,n S� '��;�.,� Phone#: 336-751-8760 Section: Lot:
! AUTHORI7.ATION FOR
, R'ASTEWATER � Tax Office PIN:#
SYSTF.M CONSTRUCTION - -
AUTHORIZATION NO: ���'�`�• p Road Name � �`t.� ; �'�`,i',t� �.Zip' <- 1 �":��,'
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmentai Health Section prior
to issuance of any Building Pemiits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Artide 1] of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
-' '` " �' ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
:y ,„„.�...�, 6 �.
," i / e y '''� 1 1'<^''�° �-'� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONIytENTAL HEAL•TH SPECfALIST DQ`I'E ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
��C�'�j;�.'
COMMERCIAL SPECIFICATION: FACILITY TYPE �f'��;#PEOPLE � #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ���}�f�7�+ DESIGN WASTEWATER FLOW(GPD) � �L� NEW SITE REPAIR SITE , l
^� ,� ` � I
SYSTEM SPECIFICATIONS: TANK SIZE �3G�J GAL. PUMP TANK GAL. TRENCH WIDTH •���-'? ROCK DEPTH t r-- LINEAR FI'. ��''��
OTHER � I,I^��k' �f^, _�!li';.� f 7*✓
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REQUIREDSITEMODIFICATIONS/CONDITIONS: f r:7��'it�+�..� C�l�� ;�'z:;'r,�t�?,,.1 t o���i,��� _`', tl���' €�i,tjt�..±�!�a�^, t �.Y�.�'�l� E�' :'-'1'�}��
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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 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
.,,,,___._.::._._..._.-......_ _
OPERATION PERMIT � n �
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AUTHORIZATION NO. '���`��� OPERATION PERMIT BY: � DATE: � a
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**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS E�y.bESCffIBED ABOVE HA BE INSTALL D IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAP'TER 130A.SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",B SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA�,TORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02(Revised)
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. �- � � DA�IE COUNTY HEALTH DEPARTMENT ����� , r�-�
• , . 1 �IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION / ;f;�v—
—____
�� *NOTE:Issued in Comp�iance With Article I I of G.S.Chapter 130a
� Sanitary Sewage Sys.t�ems � � Permit Number
Name J o `? ��� �-L�� �.�.��- _ Date ���- 1 �` N� 7 4 G �+
�
��� �ti -,
' Location �ti`��� � �`_;c�-���� �� �v +��a c � � ���1.�. �.��(,�> _
k � ` �= - � �� ` - ' -�-�
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Subdivisian Name ���7Y� � Lot No. Sec. or Block No.
Lot Size � .-�v��� L �� House — Mobile Home _ � Business --. Industry
No. Bedrooms �—.No. Baths _�_ No. in Family � _ PublicAssembly Other
Garbage Disposal YES ❑ NO [� Specifications for System:
Auto Dish Washer YES p� NO ❑ ���� � �,� �._ ��,�
Auto Wash Ma^hine YES p/ NO ❑ -
�,t�d �
Type Water Supply _—����c L�.-� ------ � � �' �U
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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Improvements permit by � ����^'�����— '--�,_;�'�
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
Final Installatio Diagram: �``"'�.�o System Installed by �C��� �`' �`�''����^-
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Certificate of Completion �-- � �° Date ���� ��
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
. „�
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` � � APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI --j-�--..a_,.,
, � Davie Counry Health Department �' ���..�,.,,. �Q ,�.���
Environmental Health Section
P. O. Box 665 �Q�� � 7 i�t�j�
Mocksville, NC 27028
__��____ —
1. Application/Permit Requested By �1�� �/ �r�k
Mailing Address R-�� � •l�flx )i����c�n1 C.� ,IJ�, �7,d�
Home Phone �9�O� °I`1�"�6�.� Business Phone �-� ���;��
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation I.�J'Septic Tank Installation
4. System to Serve: ❑ House �Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other 0 Unknown
5. If house, mobile home: Subdivision 9 `� �� Section Lot#
❑ BasemenUPlumbing
No. of People � ❑ BasemenUNo Plumbing
No. of Bedrooms .� dWashing Machine
No. of Bathrooms a dDishwasher .
Dwelling Dimensions �'� x 7� ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No.of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: C�Public ❑ Private ❑ Community
8. Property Dimensions la b x �0 5 Sewage Disposal Contractor �A�n J W h��-/�I���
9. Do you anticipate additions/expansion of the facility this sytem is ntended to serve? [�Yes ❑ No
i�
If yes, what type? -3 ���bJ�r� ��� �Ct, er
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: �����W G � '�� G(�c�.� �Ypv11 �DC1''�51/���� '�O J U y�� U
� �! /- �
�u�1u��1 �oac�. — � m, �� 0 K �e� �" f���o� (�oc� ,�-e�U U,C�10y�1�
, P
�.� �� .�-c�r��, � �
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
l- � �- � � /,�.� �...�•_n
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: C�1. I OWN the property. _, � 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 County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
-�1_I D S�
DATE SIGNATURE
DCHD(12-90)
rt � �'r
,,, • DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
• Soil/Site Evaluation
NAME � \ C9�s�— `� DATE EVALUATED �� �" � L�
ADDRESS S �' �`2 PROPERTY SIZE 1��'� � 7 b�
PROPOSED FACIILTY � ' ���� LOCATION OF SITE \�`��.�,����*{��`t,
Water Supply: On-Site Well Community Public
Evaluation By:�,��AugerBoring �,� Pit Cut ��
FACTORS 1 2 3 4
Landsca e osition � s
S10 e 7. _ I � _is� �r-c - J�-��
HORIZON I DEPTH � �
�, u
Texture rou C L t- �-L,
Consistence � 1-`T � ��
Structure � C C C
Mineralo ' \ ;� I�1 � �
HORIZON II DEPTH �� L12.` `I� " �-1 `'
Texture rou C C �'
Consistence -� f'�
Structure k. � �
Mineralo �� � 1 :� ' 1
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS S,S � s <s s S--S
RESTRICTIVE HORIZON — —' "
SAPROLITE — -� �- —
CL�SSIFICATION S S
LOyG-TERM ACCEPTANCE RATE � ,y �y ,
SITE CLASSIFICATION: � � > EVALUATED BY: \o�z� �_^��
LDNG-TERM ACCEPTANCE RATE: � v\ OTHER(S) PRESENT: �� �-�
REMARKS: �� , •� �� J � -�
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
3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Iriineralo6ty
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 w etness - Inches from land surface to free wate�' 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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