118 Western Dr Permittee's ,� 7 / ��"'/�"'" DAVIE COUNTY HEALTH DEPARTMENT
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Directions to property:�''��? �'�'�' ` 1 �� �'' Mocksville,NC 27028 Subdivision Name: �
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AUTHORI7,ATION FOR
WASTEWATER Tax Office PIN:#�7�? -1�S� � ���
SYSTF,M CONSTRUCTION
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AUTHORIZATION NO: Q�� v� � -.j 1� Road Name: Z�p:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
ro issuance of any Building Permits.This Form/Authorization I�Iumber should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 1] of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
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w--�"�: ,�i r 1 4 � ""'�r<r--,�f f"�% ,.��I �-��'�� IS VALID FOR A PERIOD OF FIVE YF,ARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE�_ #BEDROOMS�#BATHS '� #OCCUPANTS ✓�� GARBAGE DISPOSAL:Yes or No
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COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No
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LOT SIZE��./�� TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD) `�-a��' NEW SITE REPAIR SITE �/
SYSTEM SPECIFICATIONS: TANK SIZE Lr'�� GAL. PUMP TANK GAL. TRENCH WIDTH�� ROCK DEPfF�, j✓ LINEAR FT.�'�-'��
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#TS(336)751-8760.
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AUTHORIZATION NO. 2�0 9 OPERATION PERMIT • — DATE: � b `.z 3�n �O
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'"*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 0?l02(Revised) �/�/j'�� ��(�l �O�j�D ri? �v'� v��� .
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� DAVIE COUNTY HEALTH DEPARTMENT,. �
PermiUe�'s /,.--. / '�""/"�
R I+Tame;^�.r�f�' �r I , �✓�"'� �"�' Environmental Health Section PROPERTY INFORI�IATI N' � rl�//
% � �� / P.O. Box 848 } A "�r '���'"
Directions to property: �`'f f' ` `���' J �` �� 1�1ocksville,NC?7028 ' Subdivision Name: ��� �t/
` ` Phone#: 336-751-8760� •
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AUTHORI7,ATION FOR
WASTEWATER Tax Office PIN:#� ��� - IS -3 y��
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AUTHORIZATION NO: ������� 1� RU�d Namv�T P(��� • �Z°e Ks��
**NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permit�.This Fonn/Authorization Number should be presented to the Davie Counry Building Inspections
Office when applying for Building Permits.
(ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.]900 Sewage Treatment and Disposal Systems)
! f ***NOTICE***TH1S AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
`1 � ; � c=- �:-�r � i ,/�.I � �x�f IS VALID FOR A PERIOD OF FIVE YEARS.
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ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE_� #BEllROOMS_�#BATHS��#OCCUPANTS J GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
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LOT SIZE r',1�� TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW(GPD) � �r�NEW SITE REPAIR SITE�
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPECfION OF THIS SYST'EM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
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AUTHORIZATION NO. 2-�'�9� OPERATION PERMIT • ^DATE: � � ' 2 3 ' O �'
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"�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 02/02(Revised) ��L1/ �L/- �O��UO�0� _ �-/`+�•� �1J/��
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. . DAVIE COUNTY HEALTH DEPARTMENT
� `� Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
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Landsca e osition
Slope %
HORIZON I DEPTH �y a
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HORIZON II DEPTH �, '
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HORIZON III DEPTH
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Mineralo
HORIZON IV DEPTH
Texture rou
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Structure
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SOIL WETNESS
RESTRICTIVE HORIZON
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CLASSIFiCATION �"
LONG-TERM ACCEPTANCE RATE �
SITE CLASSIFICATION: � �� EVALUATION BY:�
LONG-TERM ACCEPTANCE RATE: ��`Y OTHER(S)PRESENT:
REMARKS:
LEGEND
T,�ndscaAe 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
Tex�.ur�
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
ON I T+.N .
NIQiS�
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
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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-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
1:1,2:1,Mixed
LY�
Horizon depth-In inches
Depth of�11-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-gaUday/ft2 DCHD OS/OS(Revised)
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' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME :���° � �tr� PHONE NUMBER '�/Y�����(o
ADDRESS ��� ����P�'� ��/� SUBDIVISION NAME
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