165 Walker Rd . ..�-�� r _ ' .
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AUTHO�IZATIO�NO. »' 9' �" DAVIE COUNTY HEALTH DEPARTMENT � �
�. r .� � t?�
� - . --:.._� Environmental Health Section PROPERTY INFORMATION
Perfiittee,ti ',_� �,,, P.O. Box 848
Name: � ;:.-��G ►�- `=' r C...t`� � Mocksville,NC 27028 Subdivision Name:
Directions to property: ,'.�- ` Phone# 336-751-8760 '
� � �t/ti; --I t., (:_:�:.�`�:.-Y Section: Lor.
--,� � AU VHORIEWAT�ER OR
� �f ^����`� � �L � � rv�� �� �,L��'1SYSTF.M CONSTRUCTION Tax Office PIN:# - - _
�. . r `� ,
'�'t "��:. Uti': �L--.' Road Name � U,�1�..�t;.t.. ��.��Zi : ~i�,
P -
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISS[1ED by the Davie County Environmental Health Secdon 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:
, (ln compliance with Anicle 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
, .
�`' --- ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,,._,�', � (.-��.. - �-. '�. (r 1,, ` IS VALm FOR A PERIOD OF F[VE YEARS.
�NVIR0�1 EN'; �` 'fFi SPE IA1,t�T � DATE SSU D
�� ��'
; . . .. .. ,
, , , . . .. _ , , , _ . , : ._ _ . ,
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. :��.�,�� , ; '� � ;��� DAVIE COUNTY HEALTH DEPARTMENT
"°"'"'<`` .� ' .�— -._,- TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
:� ..---�� . -
Per�hitfee s ` ; �,;.
Name: �,��'+ �• ' M+�� -'� Subdivision Name:
Directions to property: �fi �- i� � � " �� 7' Section: Lot:
, '� IMPROVEMENT
q:.1 �, . � t.... ` ,,,� .:°:�........,r PERMTI' Tax Of6ce PIN:# _ _
� r `' � . Road Name �: ,�.i'a_, Zip; s c
�
**NOT'E**This Improvement Pernut�pOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system.An
AITTHORIZATION FOR'•WASTEWAI'ER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
: ; ' ***NOTICE***THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE
-'v. ,�r� �Z. �; "� PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
, ..,,. ,. :
"ENVIRONMENTAL-HEALTH SPECIALIST DATE�D� SYSTEM CONTRACTOR MUST SEE THIS PERMTf BEFORE
q, INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE -��.� #BEDROOMS r #BATHS�#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WAS'I'E:Yes or No
� 1.��:°: � �' v ' �`:'d..��c::-�
LOT SIZE � � `'� TYPE WATER SUPPLl;�-��� t DESIGN WASTEWATER FLOW(GPD) ---- NEW SITE REPAIR SITE !%
,, 1
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH�'� ROCK DEPTH � Z , LINEAR Ff. ��---'f >
OTHER � 1.',+I�`�1�.thl„)'�"!::tJ (�C�}�
REQUIREDSITEMODIFICATIONS/CONDITIONS: ��I�►=-�`� �u+�-�'�-1=' 1.����.=�. �t.-"C'-'�����=- C-^�l^-j�= �%�-t`����'�L:, 1���.� I`�
,� .--�.-.. � -
�_.�� , i�� t �-�,.J�.NT Ur31�.Jl� '
IMPROVEMENTPERMITLAYOUT.�r.��F�OV�D EFFLU�I�T FILTE��' �`RIs���S� Z� �a�! ��LI3.-� FIr3ISli=D G��iD:'�
P��j_._. I C.��k3��',���,,
- , t�
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��571N(,�y """�,'
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��., �1��.iti �%� i�5�;�r
f(�.��7T ,,�(c'"""'1:_'aC 1 S�T I�.!,�1�., k-�G M.1�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS('���Cr���'7`6�t x
ca��y7�i—�7��
OPERATION PERMIT �1 tJ ( �� ',�Q
SYSTEM INSTALLED BY: �_l��� � "�(�?�. 1�b"
N�...TuJ 1 D� �,3tc,`�yt••
�
EXISTI�.Ib'•-►' �i '_ � L-AS'r
y �
N�.t�►
��`'� , �sr►,�6
AUTHORIZATION NO..�_ PERMIT B • DATE: � � �Z
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE TH T�- SYS�IGI-DE�RIBE 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 OS/96(Revised)
. � . r�G,
e.
, ��" ,,,�" �,� , DAVIE COUNTY HEALTH DEPARTMENT
j � � ' � � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
��,- _-�
z =
w *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
. Sanitary Sewage Systems ; ,.�!��' r� Permit Number
� �1;
' :j i . � I , v ,�,, 0 � �,
Name r;Fr, �- t -U�_-;'z. <'.:; �r� Date �' � %'� `� N_ � ._ ._ �:5
r
; , ,
: , � -i , ,�
Location rf �'�%', r ,�- , ;� r �• ';;'- i; t ';� �_';�. ..
,
� %
.
`�.'�:-� �. ' — --
�,
Subdivision Name � Lot No. Sec. or Block No.
Lot Size -'��' House Mobile Home �-'`� Business _— Speculation
No: Bedrooms �u�_ No. Baths _�— No. in Family - �%''_
Garbage Disposal YES ❑ NO ❑-' Specifications for System:
Auto Dish Washer � YES ❑ NO 0' �,,i, :�;;- , �,�;,,�fi
Auto Wash Machine YES p� NO ❑ �;�� ; 1 ::; � ;,'- ,
_ ��.�.'��it�/.` �✓' ;`'�
Type Water Supply __—
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
��._.._�_. ------._..�
;
;
_.�.-_..,
: 1�,�„r.,,_�-.-----_.,,,.�.�.�;..1�1;
�Y_
�M._..._.....�-._. --...._..._.._...,.
;�.
�
l :
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: System Installed by � -'`' �'�' ?%��`�^`, ("`%��i +'�� �
r-- _�
. _.�Y._L' t?-- __�,.��
.,. .._.�R r�.__._..._�._._.�
�
,;�
r__�.___—__...-----------'�
:
i
�_____..fa�-..-..�.,_..._ -�.�
��
� ' �•� �,,� �s.%
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
satisfactorily for any given period of time.
`^ !� '�P$LICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
� � ' �� Davie County Health Department
' Environmontal Hoalth Soction
P. 0. Box 665 �S '�j
Mock�ville, NC 27028
a mit Re uested B � �/�'� ��
1 . Application/P r y �
Mailing Address � � ��`�- �
Home Phone �Y�� - ��3 � Busines� Phone '
2. Name on Permit if Different than Above
�. Property Owner if Different th Above
4. Application/Permit For : General Evaluation S/Tank Installatian
5. System to Serve: r� Hause J Mobile Home (] Business
� Industi-y � Other � Unknown
6. If house, mobile home: Subdivision Sec. Lot�
��No. of People Dwelling Dimensions
�� No. of B�droom� � � Esasement/Plumbing
Na. of Bathrooms I -� ^ Basement/No Plumbiny
�. �
�Washing Machine �J 'Uishwasher � Garbaqe G:�spusal
JQ�. If business, industry, other : Specify type
/"�
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories Na. of Watar Coalars
No. of Showers
8. Type of water supply : Publ�c � F�rivate (� Communir.y
9. Property Dimen�ions � GL�uu—
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expan�ions o� the facility this system �.s
intended to serva? � Yes �o
If yes, what ty}�e?
*NOTEs Improvements Permita ahall be valid tor a period ot 5
years from date issued. Improvements Permits are subject
to revocation, if aite plane or the intended uae change .
Effective October 1, 1989.
This is to certify that tne infarmatior� pravided is correct ta tne
best ot my knowledqa, an� I understand I am rF�sponsible far all
charges incurred frc,m tt��is applicatian.
/ -�- �l '1,�1�� 1� � � �
Uate Signature
UirEctions to Property :
DCHD (10-89)
�
w
` ,- �'' �_, � ' DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
NAME _ �/,��i�� DATE EVALUATED � 'y 1 D
ADDRESS PROPERTY SIZE ��G
PROPOSED FACIILTY ��Y. LOCATION OF SdTE �1f!-�/�rG�`
Water Supply: On-Site Well Community Public r/
Evaluation By: AugerBoring f� Pit Cut
FACTORS 1 2 3 4
Landsca e osition L 1 L L
Slo e 7. �
HORIZON I DEPTH -- �- — f
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH -C,i�'* L �r 1�p * Frr
Texture rou L G
Consistence � � � F%
Structure P/� � s-�, �
Mineralo r /,�� • i
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION ,
LONG-TERM ACCEPTANCE RATE -< <
SITE CLASSIFICATION: EVALUATED BY: ,��
LDNG-TERM ACCEPTANCE RATE: � � OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscnpe 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
Moist
VFR-Very friable FR-Friable FI-Finn 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
Structurc
SC-5Yngle grain M-Massive CR-Crumb GR-Granular ABK-Mgular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo6�y
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 watet' 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/ftz
DCHD(01-901
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. n � DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT� REMODELING o RECONNECTION o
/� � �i�- Z-- 2 2
Name: l.�l_��E �� , 1 � Phone Number: �� (Home)
Mailing Address: �DS� I�ALki%� �1� (Work)
M.oCJ�S V1U�
Detailed Directions To Site:
Property Address: ����r1�--�L
Please Fill In The Following Information About The Existing Dwelling:
Name S ste Installed Under: CL L S�� �4T �'�`�� Type Of Dwelling: �• Nd��d
� 3 ��1�1 Z
TC �i S ��
Date System Installed(Month�ay Year): Number Of Bedrooms:_ �� Number Of People:
Is The Dwelling Currently Vacant? Yes❑ No� If Yes,For How Long?
Any Known Problems?Yes❑ No❑ If Yes,Explain:
Please Fill In The Following Information About The New Dwelling:
„�� �45;�a i
Type Of Dwelling: ��t7Sl� Number Of Bedrooms: � Number Of People:
Requested By: Date Requested:� 0�
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved
Comments: � �- �.���17 � �Z �D C'��('pQ r.1� J`f�
Environmental Health Specialist Date �
""The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a �
guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash❑ Check❑ Money Order 0 # Amount: $ Date:
Paid By: Received By:
Account #: �J � � Invoice #: �- �� c�