855 Redland Rd ` ' ' ' DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street "
� . �� Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
REPAIR OPERATION PERMIT
Ae�ou�t #: 990001648 T�x PIN.%EH#; 5862-26-0978-REPAIR
Biflcd To: Terry Smith � Sut�divisior� Info: ��
}��fer�r�ce Na��e: REPAIR PERMIT � LocaiioniAddr�ss:'8'5$�Redland Road-27006 � '
f�rnpos�c9 Faci€ity: Residential Repair �� � Pro�rer#y�8ize:'�=; 16 Acres - - -
�T'�"���The��s��iance of this Operation Permit shall indicate the system described on the ATC 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. •
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r�`f �
". $ystem Type:��_S.T.Manufacturer Tank Date � �5 Tafik Size�
Pump Tank Size •
System Installed By: ���'; o �d J'ABS E.H.Specialist: i���� e: J—�d �6 (
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GPS Coordinate:
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DCHD 11/06(Revised)
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�� DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
• ' Mocksville,NC 27028 -
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION. �
Accaunt #: 990001648 T�x PINrEH#: 5862-26-0978-REPAIR
Bifled To: Terry Smith � . Suk�divisior� Info: $�j
Re�er�r�ce Name:' REPAIR PERMIT � LacationiAddress:,� Redland Road-27006
Pra�osed F��iEity: Residential Repair � Pro�erty Size: 16 Acres
. Site Type: ❑New epair ❑Expansion �
r�TC E�umber: 5747 .
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to.issuance.of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specilications: #Bedrooms � #Bathrooms l #People � Basement� Basement plumbing0
Non-Residential Specifications: Facility Type #People #Seats �
( , Square Footage(or Dimensions of Facility)� �
Lot Size /!/QC�L� Type of Water Supply: ❑County/City ell ❑Community.Well
System Specifications: Design Wastewater Flow(GPD)�'T�Tank Size�1�'��AL!Pump Tank GAL.
4 �i r �
Trench Width �� Max.Trench Depth 3� Rock Depth �a— Linear Ft.�
Site Modifications/Conditions/Other: .
_, Contact the�avie County Environmental Hefilth Section for final inspection of this system between
8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health.Specialist Date:
DCHD 11/06(Revised) "
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t ` DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �/ PHONE NUMBER �5��55/Q�
ADDRESS � •A ��P�/C��7U l�� /7(�C(�G�h�G'e SUBDIVISION NAME
LOT #
,
DIRECTIONS TO SITE � � N l� be,�`o�e G(l�(�D ti
�QQ Gf l�� i�E � � �d�tls (�
DATE SYSTEM INSTALLE ���5 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY W�°�� SPECIFY PROBLEM OCCURRING,�a/✓���,L�. /l�Nt�°S
r�e�5 ,
DATE REQUESTED,,'S' �"!��I INFORMATION TAKEN BY
This is to csrtify that the information provided is conect to ths best of my knowledga,and that I underatand I am nsponaibie for all charges ineuned trom this appiication.
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SIGNATURE OF OWNER OR AUTHORIZED AGENT
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 3/14/2011
' DAVIE COUNTY HEALTH DEPARTMENT
� • ' Environmental Health Section
Soil/Site Evaluation �
, APPLICANT INFORMATION PROPERTY INFORMATION
y�r 5.�,�� $5 5 ��f C�
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Water Supply: On-Site Well Community Public /
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition
Slo e% (
HORIZON I DEPTH —
Texture rou C
Consistence
Structure
Mineralo
HORIZON II DEPTH '
Texture rou
Consistence
Structure
Mineralo �
HORIZON III DEPTH
Texture rou
Consistence
SWcture
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � J EVALUATION BY: ��t/ < < N �
�-
LONG-TERM ACCEPTANCE RATE: �'a'?� OTHER(S)PRESENT: '
REMARKS: ,
LEGEND
L�ndscane 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
Textiug .
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
ONSI4T .N E
�1415� _
VFR-Very friable FR-Friable FI-Firm VFT-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
S�L1i�tilT�
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky ' .
SBK-Subangular blocky PL-Platy PR-Prismatic ' `
]Viineralogv . .
1:1,2:1,Mixed
lYotg� �
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-tertn acceptance rate-gaUday/ft2 DCHD OS/OS(Revised)