393 Cornwallis Drive Lot 16 AUTHORIZATION NO: 10 7`5 <DAVIE COUNTY HEALTH DEPARTMENT
-' Environmental Health Section PROPERTY INFORMATION
Permittee's P.O.Box 848
Name: ,�Y_?y `-' `"� Mocksville,NC 27028 Subdivision Name:
{' O.Phone#:704-634-8760
Directions to property: ;� ►. "1 L� t ha•��4�,`,�}� Section: Lot:
+. AUTHORIZATION FOR _
WASTEWATER Tax Office PIN:# �� J�1,7
SYSTEM CONSTRUCTION
Road Name: ! 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)
/t '7 rs
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIROI*IM4k�-A.L HEA SPE A IST DAft IS ED .
` V DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION P1,RMITS PROPERTY INFORMATION. i
Peunitfee s
t r
Name' +. " '1y"^�+• „I r :tSubdivision Name: �,L)I", `)
-Difdctlons to property: r=': (. i t�,;,. i,,,= . . r:. (,e
Section: Lot:
+, EUPR VENTM
�'r. •L, r E �t c :. _.P.ERITOffice M . ax a PI #.:,�tf
- T N: `. -
r";" Road Name �,.t.):.v,,l t• Zip:
**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 1 I 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
ENVIRONMENTAL HEALTH SPECIALIST 7,) DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
-- INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS -�-S-#OCCUPANTS - GARBAGE DISPOSAL: es or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT � #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY lam" DESIGN WASTEWATER FLOW(GPD) ..�/`'o NEW SITEREPAIR SITE
SYSTEM SPECIFICATIONS: TANKS'
ANK SIZE LE)GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. ',
OTHER "'. P151f 1F51)rIL14 P)6
REQUIRED SITE MODIFICATIONS/CONDITIONS: lP.���p'-� 60 C-Ot-)TOOZ h'trl=T-a I-►^*fir..`-S td�� %`�= --
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IMPROVEMENT PERMIT LAYOUT - ° """ x(>C➢�
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**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 .4
\1,
SYSTEM INSTALLED BY: )C
AV
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go'
124�'
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AUTHORIZATION
--AUTHORIZATION NO. OPERATION PERMIT BY: Z
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIEQABOVE 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 05/96(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC 34�1G
r Davie County Health Department
Environmental Health Section n—
THE
P.O.Box 848D
Mocksville,NC 27028SEP(704) 634-8760****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED NLESS A� REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed � Contact Person
Mailing Address v Home Phone
City/State/Zip 17"c,,'& I-Vr— 27022 Business Phone 222)
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ ] Site Evaluation [aJ(Mprovement Permit&ATC [ ]Both
4. System to Serve: [.Jj House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People-_ #Bedrooms #Bathrooms .3r [ Dishwasher[- Garbage Disposal
[ Washing Machine [ ]Basement/Plumbing [/fBasement/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: [/County/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [4
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***•ViXLW OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: /r /�C WRITE DIRECTIONS(from MocksvUle)TO PROPERTY:
Tax Office PIN: ##
Property Address: Road lame Com r'-J7
City/Zip hV.--&'L/
If in Subdivision provide information,as follows:
Name:
Section: Lot#: (�
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 Count Health Department to enter upon above described property located in Davie County and owned
by � , Q)
l �1✓ 7a t-- L 1tqscondurtall testin r ures as necessary to determine the site suitability.
DATE SIGNATUREy �� i
Revised DCHD(06-96) 4 Ct
THIS AREA A(AJ 13E USEI) FOR DRAWINC7 YOUR SITE PLAN:
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-' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAMEDATE EVALUATED
ADDRESS PROPERTY SIZE �f�C
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position lop T_
Sloe % 14 1
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 46 r
Texture group
Consistence r-
Structure
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: EVALUATED BY: �
LONG-TERM ACCEPTANCE RATE: " _._.& OTHER(S) PRESENT:
REMARKS: .�c'P 4n��� �Q��'
-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
3C-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
DCHD(01-901