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110 Taylor RdPermittee's Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848 Pd 3 0 PROPERTY INFORMATIOrl., Directions to property: i ,- "' Mocksville, NC 27028 Subdivision Name: C.i:(,,► v_ y,: Phone #: 336-751-8760' Section: AUTHORIZATION FOR Lot: SYSTEM CONSTRUCTION Tax Office PIN:# AUTHORIZATION NO: A Road Name: 1 !, f0i�'LL_'i'- Zip: �' ^r **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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) % i ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL4HEAL-rH-SPECIALIS.7"' DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS »`✓ # BATHS 2— # OCCUPANTS L' GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY `' ✓�T'� DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE _ t SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK 1 GAL. TRENCH WIDTH _" ROCK DEPTH k31&- LINEAR FT. OTHER A. .�L �) l;l J �-. _ , C� �f� /[=16 ` .= r 1�7 t21 r��T ►U� l REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT I "I ,1°._I,:x i H 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. 11 OPERATION PERMIT SYSTEM INSTALLED BY: xl� S�6z� AUTHORIZATION NO. pr' OPERATION PERMIT BY:J4 )-DATE: `t) a OfO **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 0= (Revised)/Pal�' q0 000 �9 -I-V , V ¢; t,',"v Perrniuee ss. Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATIOrl,�j P.O. Box 848 Directions to property: `` Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-876C , .. ...-„,,.�t. •.. .. Section: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:#_ AUTHORIZATION NO: 002r,91 A Lot: r j Road Name: �' ' ' Z'' Zip: **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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL EALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE r�IA # BEDROOMS p=” # BATHS -=— # OCCUPANTS 41 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No t�"r 3 ~�=-� LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GrAL. PUUMP TANK _ GAL. TRENCH WIDTH .`- ROCK DEPTHQ _ 1 h - LINEAR F'T. OTHER f 1 REQUIRED SITE MODIFICATIONS/CONDITIONS: �`$- A -AL- IMPROVEMENT PERMIT LAYOUT jr 4 j_- k4t.t_L- L..� 1 . t: tri, -i ty �:• t1 z �r 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 r- A SYSTEM INSTALLED BY: 4+^�t'� AUTHORIZATION NO. Q OPERATION PERMIT BY: DATE: a 0J� } "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DE IBED ABOVE H S BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 07102 (Revised) j�r� / f / ice) /fit %V Z� 27 V . -,r I 7" ! V � 'e� 1 Mn'1vC 1E��� TA,J iC 1Jj42 tsc'S DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NE I 1 be� E Con PHONE NUMBER ADDR DIRECTIONS TO SITE J SUBDIVISION NAME LOT # DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY %-- NUMBER BEDROOMS 3 . " NUMBER PEOPLE SERVED TYPE WATER SUPPLY � ' I SPECIFY PROBLEM OCCURRING 2�AW W&?- &01 DATE REQUESTED tob IrJ 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. 1/93 t l {. — MI -00 d/' M ,� �+� � � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION 10Water Supply: On -Site Well Community Public �- Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 11 Slope % SSf Y10 HORIZON I DEPTH Texture groups Consistence Y Structure Q Mineralogy�= HORIZON II DEPTH 13 - 1 Texture group </ 0 SC.t_ Consistence P hrr q 7 C.5 519 Structure Mineralogy HORIZON III DEPTH -'32 - Texture groupSC- Consistence Structure 531c Mineralogy HORIZON IV DEPTH Texture groupc Consistence Fr SS S Structure ` Mineralogy5. SOIL WETNESS -- �- RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O• SITE CLASSIFICATION: V > LONG-TERM ACCEPTANCE RATE: c)' REMARKS: EVALUATION BY:yd--E &A�/`�"`' OTHER(S) PRESENT:) e` q U� 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 ois 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 - Nat plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - 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 DC14D 05/99 (Revised) C ■ ■�A ■������������������� ■����������������������������■ ...�.�..................�C.............................. 6 �.. ..................�..............................� . ................. . .............................. . �. 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(/,/� ���"'S' .,s" i,''�& i 5i .��'� �°m�� a�a � �+� �^"� ��� y " }�;`yi �a'*vi cn.�.+. .. .. . . -... .n.�,l.SDlc,.^ . 4.. ..��6.- ."���W .,s,e"_ L.'�rsr.t...`aSnaY. .,> .t..e., ._.,. ..,.��. wi'3` x� Y --:tP .a.. �:� APPLICANT INFORMATION Account #: Billed To:--c���i Reference Name: 1 Proposed Facility: Water Supply: Evaluation By: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Property Size: Community Auger Boring ✓ Pit "�T? C/--A-- PROPERTY INFORMATION Tax PIN/EH #: Subdivision Info: Location/Address: Date Evaluated: Public Cut ;D -6,00 `Y FACTORS 1 2 3 4- 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group L - Consistence Structure Mineralogy , HORIZON II DEPTH ; Texture group Consistence Structure Sk5 i, MineralogyS HORIZON III DEPTH Texture group Consistence Z Structure s Mineralogy HORIZON IV DEPTH Texture groupt' Consistence r Structure C_ Mineralogy SOIL WETNESS '— RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND Landscape Position EVALUATION BY:-- OTHER(S) PRESENT: 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 'SC - 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