110 Greene Court Lot 4o
AUTH`62IZATION NO: 0980 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Pefmittee's ¢-;;- ,f P.O. Box 848
Name: * .rte �' �'' ;,��"t,��r� Mocksville, NC 27028 Subdivision Name:'"
�s�, Phone #: 704-634-8760
Directions to property: t' '.� ? � t �'r Section: Lot: e
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#�S
W 6 e v j r SYSTEM CONSTRUCTION r f ��tt - Q
AI
Road Name: 61 e ccy) E 1___VAp:.�"
**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 Fonn/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
�;,s t • :'`/,;:r ''-, r' ' t;1 " IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH PECIALIST DATE ISSUED
a� t ; , DAVIE COUNTY HEALTH. DEPARTMENT 7
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Puttee's f,,a ,:,� _, �•'%y'J _ f'�
Directions'{o property: fl%
Subdivision Name: 4.21,%. `•24 7 D 14 '"
Section: Z Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# s; :- - -
1 / t l"<,c.} ?-r�--' � Zip:
Road Name:
**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
construction/installation 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)
' ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE -I71 # BEDROOMS #BATHS S" #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) 'l� NEW SITE Y REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE,/. T)f- GAL. PUMP TANK GAL. TRENCH WIDTH •1C' / ROCK DEPTH -A7 LINEAR FT.. S
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**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 y
ZQ z &*STEM INSTALLED BY: KAJVV ' I A 1LL GQ
C' I1oG
NoT..
cv cep,
t^r'' y j eo
I �� IDo' 18" 2ey-' k
00
LAHASAUTHORIZATIONNO. ()9*v0 OPERATION PERMIT BY:DATE: � **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE STEM DNSTALLED 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)
1366
APPLICATION FOR SITE EVALUATIONAMPROVEMENT P
Davie County Health Department D
Environmental Health Section
P.O. Box 848 JUL 2 2 1997
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed
S k - 1J- —
- , �, - T,- o _ Contact Person
Mailing Address
/ 2- 57 U S ,�
f_, -1 w Home Phone
City/State/Zip
J- C-- Z 7 o t Business Phone
`l `� l) - 7 1 t Y
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [ ite Evaluation
City/State/Zip
Permit & ATC [ ] Both
4. System to Serve: [-TIffouse [ ] Mobile Home[ ]/Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms `-' # Bathrooms 3. -" [,.J-Di-shwasher [-+Ekarbage Disposal
[ Wishing Machine [L4-B-asement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [ unty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [-+?lo
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** ATVWOF THE PROPERTY MUST BE
yy SUBMITTED WITHTocksville)
]�S APPLICATION.
Property Dimensions: a > �c �`� 2 / �Y, / r WRITE DIRECTIONS (from TO PROPERTY:
Tax Office PIN: # 5,' y I y
Property Address: Road Name / 4/ _ Ph
City/Zip
� 2. r
If in Subdivision provide information, as follows: `Tr
Name:
Section: Lot #: o
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by le g s > t- - . div - :. L-. to conduct all testing procedures as necessary to determine the site suitability.
DATE / Y `T 7 SIGNATURE —c"
Revised DCHD (06-96)
THIS AREA MAY 13E USED >`01z WaIVINC7 YOUR SITE PLAN:
'�i 1"i;'�/7 `� ala'/ 1' � R /-t10 e1J, 7 4: 5 r 0.'
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME =C P DATE EVALUATED
ADDRESS
PROPERTY SIZE �dC
PROPOSED FACIILTY-,��1�rIf LOCATION OF SITE a �� G
Water Supply: On -Site Well Community
Public
Evaluation By: Auger Boring Pit /---, Cut
FACTORS
1
2 3 4
Landscape position
L
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupL
Consistence
Structure
h.e
Mineralogy/
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: JT EVALUATED BY: //_'Z1_ I le—
LANG-TERM ACCEPTANCE RATE:
REMARKS: she zmey-n
DCHD (01-901
OTHER(S) PRESENT:
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-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
Mineraloey
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