952 Yadkin Valley 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
�cct�u�t #: 990005814 '��x�I�€:EN#: 670000009203
Biilc�To: Randy Riddle ���E��ivi410f1 If3�t7:
Re:fer�r3ce N�r��e: REPAIR PERMIT LacaiionrAdr�r�ss: 952 Yadkin Valley Rd-27006
E�ropc��ec9 F;��:iEiEy: Residential-Repair , t�rr���r�.y �iz�:: _, 7.49 Acres
�C�Ar�-5872
p,-€-�*�'�*� T1��uance of this Operation Permit shall indicate the system described on the ATC has been installed
m compliance wi'th 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.
System Type:_�_S.T.Manufacturer � K Tank Date�_ Tank Size /
Pump Tank Size / ���
� � j, �q���
System Installed By:�y��(/��Q I 'lC. E.H.Specialist: (� �"I3ate: /�/�jo���Z
��``Y-- �'7��f--
GPS Coordinate:
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DCHD 11/06(Revised) -
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 CONSTRLJCTION �
�Gc���3t #: 990005814 i"�x F'I�€iEH#: B70000009203
��Ilc� Ta: Randy Riddle �uk��tivi�io�� Ir3t��:
��€er�r�ce �Ea€��e: REPAIR PERMIT Loc�iliortlAd+�r��s: 952 Yadkin Valley Rd-27006
f�ro�t�ssc� F��;iEity: Residential-Repair ��o�����; -��j����air ❑Expansion
�Te: 5��z
���'�'�'j���'hi��ghorization 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 FNE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms #Bathrooms�#People Basementf�l Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats •
Square Footage(or Dimensions of Facility)� � .
Lot Size .y � Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)<�►�v Tank Size(? v AL.Pump Tank �GAL.
I( � , . � �.__�__.
Trench Width� Max. Trench Depth� Rock Depth r�/� Linear Ft. ZQ �/�'
Site Modifications/Conditions/Other: �C�G���`�
� Contact the Davie County Environmental He�lth 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)
�iUUO!•�'� �OD l.3
� �-d�a�9z��
� � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION l��c.r�AG'��'S
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �l� I� PHONE NUMBER cJ� �7�/ ��
ADDRESS ��� �GtC�I F511� V(�-�(X,p.� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE � � �x�`l" � �d� Q�� N����� �� �l1�
� � Y �
DATE SYSTEM INSTALLED "!��-�,NAME SYSTEM INSTALLED UNDER� l
TYPE FACILITY C(SC�i NUMBER BEDROOMS � NUMBER PEOPLE SERVED
TYPE WATER SUPPLY � � SPECIFY PROBLEM OCCURRING � /�
/ L;,��s
DATE REQUESTED `� l INFORMATION TAKEN BY -
This ia to certify that the information provided is corced to the best of my knowladge,and that I understand I am rosponaible for all charges incurred}rom thia application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93
/ !: DAME COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
t—NOTE: in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit-Number
6r� ✓ny h; rruye r�f� xhY6J� ate No 115U
Name _
Location
/6i *e F !/a//y Oi�� �,✓ �lr
Subdivision Name Lot No. Sec. or Block No.
/. %61ie
Lot Size "Jr House Mobile Home —,tj Business Speculation
No. Bedrooms .No. Baths No. in Family
Garbage Disposal YESNO ❑ Specifications for.System.
Auto Dish Washer YES $ m.
NO ❑ a�•ev, AOr••C
Auto Wash Maohine YES 01 NO
El -.�X�`I 47,
G
Type Water Supply __—
'This permit Void it sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation it site plans or the intended use change.
Y
// / J
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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: 106 System Installed by
r
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
satisfactorilyfor any given period of time.
� �� � ��
.�
�, ' - ��J APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT __,_.,,;,:..--
J' _.._..
��' �� � Davie County Health Department �"" '
,._.-_._
� � � � � Environmental Health Section -' ' .
�1 D� P. O. Box 665 �'
`;
(� /)li � M o c k s v i i l e, N c 2�o z 8 ��L 2 � `g g g `i
l./"
. � � J ��8���
1. Application/Permit Requested By + 1'��u �! � te. ' ��°��'� �� `' `;� �',� "
- ,,
_ _._____. _�_. .
Mailing Address���-e. �u�c 154 Ad�/u.nce NG ��oo�
Home Phone ��I�r� q 4U- LU�l0 Business Pho eG�����" ��'S�
2. Name on Permit if Different than Above LC� �1 i;ddle.
3. Application/Permit for: ❑ General Evaluation �Septic Tank Installation
4. System to Serve: U�'House ❑ Mobile Home ❑ Place of Public Assembly
O Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
Q�BasemenUPlumbing
No. of People Yl`l�l�(� a �C-G�5 ❑ BasemenUNo Plumbing
No. of Bedrooms 3 � shing Machine
No. of Bathrooms `� Dishwasher
Dwelling Dimensions�fLY Lf 9 � � 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 Dimensions � . qlD A�,p p� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes O 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: ,Z jf� �td Sd f 7-V,�/�/ /�z��� D./� �'�� `�9'���/
/�� - c�� a -D �X.0�S �Jrezd'�w�qy /3�£7Gvf�,���5.7 7`Gva
�l.C:�C�' ,�jr/d"/f,� �C3�1'Fo.�� you 4�7 j0 �j��/,Q'1' oA�,�-S�
�t�v- �' _,�� �w��-^� ��'���
-. ��ei�� . /' �r-�v� �o��
---� -., � ���
� �
,c�p'�� _. . _ .
,Cgc��'^- r`��`
o� /Slda s,� • � �
This is to certify that the information provided is correct to the best of my knowledge and I understand I am sponsible for all charges
incurred from this application.
'7-/�- 9-3 .ti '
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: �OWN the property. ❑ 2. 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 representativ of e Day ie Count H alth Department to enter upon above described
property located in Davie County and owned by , `�. �GX�fX/�
to conduct all testing procedures as necessary to dete ine said�site's suitability for ground sorption sewage treatment
and disposal system. �
;�-1�- a �
DATE SIGNATURE
DCHD(12•90)
t
,. `
_� ''r � '✓ DAVIE COUNTY HEALTH DEPARTMENT
:� Environmental Health Section
:� Soil/Site Evaluation
NAME ��� r DATE EVALUATED _ __ ����`�3
ADDRESS PROPERTY SIZE l. "l��
PROPOSED FACIILTY �: v�%`�G1S� LOCATION OF SITE VI�C�• �', O�G,
Water Supply: On-Site Well Community Public ��
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landsca e osition .�- �-- �.
Slo e 7. �
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH ..� P'
Texture rou G �
Consistence i � �
Structure ,� /
Mineralo - '. '/ -
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASS.LFICATION
LONG-TERM ACCEPTANCE RATE �
SITE CLASSIFICATION: EVALUATED BY:
LANG-TERM ACCEPTANCE RATE: i OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Footslope 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-SYngle 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 w etness - Inches from land surface to free watef 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
DCND(O1-9o1
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