762 Sain Rd D
1W -WV
AUTHORIZATION NO. 0523 DAVIE COUNTY HEALTH DEPARTMENT 2 0
Environmental Health Section PROPERTY INFORMATION
Permittee's P.O.Box 848
Name: Mocksville,NC 27028 . Subdivision Name:
' �� Phone#:704-634-8760
Directions to property: i►3i:✓ i�" 7 Section: Lot:
AUTHORIZATION FOR
WASTEWATER
' SYSTEM CONSTRUCTION Tax Office PIN-#-- -
Road Name:_'�a l Zi �o
p:
**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 l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
ar ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
V � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEAL'fff SPECIALIST DATE ISSUED
i
ri.{y,ya'y ✓�'Sr..r^'Y-y FY1�'r! 1"%fy-, '! .:;(.'r.v+•`•�b"w ,.rrr'*:1-.t }..y ... v F. °:.17 A ,-. r: y r.t>•... ;t r ,9.i' t ��. G
DAVIE COUNTY HEALTH DEPARTMENT rj�0
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
e+W' tte .
Name , r t Subdivision Name: I
Directions to property: r5i,;y "I rl' Y Section: Lot:
IMPROVEMENT
_
PERMIT Tax Office PIN:# 1
Road Name: Lt t i �f•a-• Zip: ' r
**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
constructionliinstallation 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) '
1 / ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
e�A � C.{� -r _ � �' �. PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALY11 SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM. V
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS �}_#BATHS 22 #OCCUPANTS GARBAGE DISPOSAL:Yes or No�^
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT' ..� #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY r O DESIGN WASTEWATER FLOW(GPD) rb NEW SITE REPAIR Srm
SYSTEM SPECIFICATIONS: TANK SIZE.4t GAL. PUMP TANK GAL. TRENCH WIDTH l ROCK DEPTH f-? LINEAR FT.J!",00"
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
i
**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: \>QR N O a
AUTHORIZATION NOO S 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 05/96(Revised)
« qq
` r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
f Davie County Health Department
Environmental Health Section
P. O. Box 665
I� Mocksville, NC 27028 _
r
1. Application/Permit Requested By.
Mailing Address V3 3� �� � �►0-1n Home Phone `?1o'-7&&-&3 7-9
f,.)).S 12 4- 73 103 Business Phone SAn1
2. Name on Permit if Different than Above
3. Application for: NA
eneral Evaluation ❑Septic Tank Installation Permit
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
- ❑ Basement/Plumbing
No. of People [Jd Basement/No Plumbing
No. of Bedrooms "� [y Washing Machine
No. of Bathrooms. Dishwasher
Dwelling Dimensions 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: Public ❑ Private ❑ Community
8. Property DimensionsSewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
"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:
.�
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.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. I OWN the property. 4 2. 1 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 represental4aof the Davie County He Ith 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.
DATE SIGNATURE
DCHD(1 193)
DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section
Soil/Site Evaluation
NAME U GlcA `t DATE EVALUATED
ADDRESS S f� n``p1` PROPERTY SIZE
PROPOSED FACIILTY n o 0 LOCATION OF SITE R t r� RO IN A
Water Supply: On-Site Well _ Community Public 1/
Evaluation By: L.Auger Boring Pit // Cut
FACTORS 1 2 3 4
Landscape position -s
HORIZON I DEPTH 1,J. &a, L
Texture groupL, C L L C L
Consistence
Structure K �-
Mineralogy ;)
HORIZON II DEPTH
Texture group (Z-
Consistence
Consistence �S FT }
'Structure 13 k
-Mineralogy ) ' 1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS SS 1 3 S ,S
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE____,L, , 1} �+
SITE CLASSIFICATION: F. EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: 4 OTHER(S) PRESENT: Ivo N
REMARKS: �e� C \ A`1 5(_h " 4
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-Angular 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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Davie County NealK Deparbnent �
and Nome Nealtfr Ayency
210 HOSPITAL STREET/P.O. 80X 66S
MOCKSVILLE, N.C. 27028
PHONE:(704) 634.5985
February 16, 1995
Ricky Tesh
4330 Cordova Dr.
Winston—Salem, NC 27103
Re: Site Evaluation
Sain Road/6 Acre Tract
Dear Mr. Tesh:
As requested, a representative from this office visited the aforementioned
site on February 15, 1995. Rased upon the information provided on the
application for site evaluation and after the evaluation was completed, the
site was found to be provisionally suitable for the installation of an on—site
sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Charles E. Little, R.S.
Environmental Health Section
CL/wd
Enclosure