648 Richie Rd 4.,':. .. - 1 f-�.•.�. -. �.i•. ,.�:.: .'....z r_.`�::''J P:�y""'i j�'+'V.✓^Sn.��yyoS-V Fy�,�;�� 3 n i ..
Permittees A J� .,
,DAVIE COUNTY HEALTH DEPARTMENT
):Tames ''t�� V - Environmental Health Section PROPERTY INFORMATION
�w C11►�.� ,� P.O. Box 848
Directions to property: Mocksville,NC 27028 Subdivision Name: 1r2)07)_U
7
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bra CT> Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION r �* --7 7
-
AUTHORIZATION NO: 002816 A Road Name: —Zip: 4~1 V 2UU
**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 compliancy-with Article 1 I o,G.S.Ch9pMT 1130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
// �. ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/U 7� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRO NT LTH S IAL,<T DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE daisc#BEDROOMS 2 #BATHS ( #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TY1P.E1 #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLYDESIGN WASTEWATER FLOW(GPD) "I NEW SITE REPAIR SITE
" 1
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH ��'`LINEAR FT.
OTHER C, ij G-��a 1Z-0117>OCT 1 C J �i l%��
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYQUT
I
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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.
OPERATION PERMIT roy wL�
S�S�Ew1 INSTALLED BY:
e }�
1
AUTHORIZATION NO. ��✓(�4 OPERATION PERMIT B DATE: O
Loll V
.*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE STEM 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 NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIO{D OF TIME. �f
DCHD 02/02(Revised) fi/)/j 1.� 11110 �V r 6 01 V /-
PenrHtf1 Is RAVIE COUNTY HEALTH DEPARTMENT
lyamea ��>v*1� •1-h V I Environmental Health Section PROPERTY INFORMATION?d
P.O. Box 848
' _/0-1
Directionsto,property: Mocksville,NC 27028 Subdivision Name: ,`�`J
Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
002816
SYSTEM CONSTRUCTION - !!}}
AUTHORIZATION NO: 0 0 2 81 S A Road Name: Zip 16 L)
**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 Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chi Mr,130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
dd ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
E&VI NTA 1-qE-ALTH SFEFIAI-e DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE V 3#BEDROOMS #BATHS I #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY Y -k+L— DESIGN WASTEWATER FLOW(GPD) L � NEW SITE REPAIR SITE
'
SYSTEM SPECIFICATIONS: TANK SIZE �----GAL. PUMP TANK GAL. TRENCH WIDTHROCK DEPTH IFS LINEAR FT. f ,
OTHER L-ITC:' G� �d 1 C�u.1 l� —T 1 v--� '(-y j l /�/`�► I
REQUIRED SITE MODIFICATIONS/CONDITIONS: � ��%Mzk
7 ? - �n✓�-u--? 4=�= r C��`F i �`�{
IMPROVEMENT PERMIT LAYOUT
-it 11
;t
`p � [�.t�.�• L�fit..
44
J ,
1A] -1
ro l
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Ir
S
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.
OPERATION PERMIT �ST� LLL
S1G1 INSTALLED BY: �J
� J
2
F� r
iW
s�
AUTHORIZATION NO. �/n OPERATION PERMIT BY. DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE STEM 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 PEER'RI'OD OF TIME.
DCHD 02102(Revised) /}
/I• 6. /i / ! /
AVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAMES weyt PHONE NUMBER
ADDRESS W".�'�� C�H1P IZ,I r I�OSJG SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDPj,0OMS Z NUMBER PEOPLE SERVED
TYPE WATER SUPPLY /6frj SPECIFY PROBLEM OCCURRING
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.1193
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GoMAPS - Davie County NC Public Access Page 1 of 2
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http://maps.co.davie.nc.us/GoMaps/map/print.cfm?CFID=11225&CFTOKEN=5442 8949 10/29/2007
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring _ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca a position
Slope %
HORIZON I DEPTH >tif
-
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH luAte
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture Eroup
Consistence r
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: - EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S -Shoulder L-Litfear 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
YYet •
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
StructurC
SC- Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineral==
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 05/05 rRPvi-,ndl
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