159 Shannon Drive Lot 4 AUTHORIZATION,NO: 0796 DAVIE COUNTY HEALTH DEPARTMENT � D�
Environmental Health Section PROPERTY INFORMATION
Permittee', P.O.Box 848 Q
Name: -J 11/1 Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property:� Section: Lot:
. � AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#�- -
SYSTEM CONSTRUCTION J
Road Name:` e r r Ll't.zip: "I, d (10
**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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
j•' <..•;•V a"��r ��!� ;�?i"j I ,/��/ "� � IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
„ . DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION ,
Permitt a
Nan4Z'
Subdivision Name:
_4 t”
Directions to property:. 'x-41 1, 'e��F Section: J Lot:
IMPROVEMENT
-_ PERMIT Tax Office PIN:#
Road Name: I t?Y't't. L'1'\,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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
f_ ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
,, !t= f. .,•''J PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE , #BEDROOMSe�.r #BATHS rn#OCCUPANTS_-41 GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE,,f #PEOPLE #PEOPLEtSHIFT J/ l�#SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE " 6 TYPE WATER SUPPLY /(� DESIGN WASTEWATER FLOW(GPD)yl v NEW SITES REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE '2GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH—e!�J—�LINEAR FT. ��✓�!�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
1
**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
SYSTEM INSTALLED BY:
a
FeD4T
AUTHORIZATION NO. OPERATION PERMIT BY: �? DATE:
**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 05/96(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC
Davie County Health Department -
y `e ,Vs-f. Environmental Health Section
W�Fr �
P.O. Box 848
�aAocksville,NC 27028 MAR 2 4 1997
t r 6A-f' (704) 634-8760
****IMPORTANT*** THIS APPLICATION CANNOT BE PROC
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed--'J O h /U �/��/ - -� Contact Person 7 " I Al
Mailing Address l 2 / L)/L-L)/L-�/2OU� -LCJ_ Home PhoneG
_ ! / c7 9 7F'2
City/State/Zip AV A AIC t- /VC Business Phone %7 0
2. Name on Permit/ATC if Different than Above M e-
Mailing Address j 4 'Zr City/State/Zipl/.Ni !UG fzf `UC-
3. Application For: [ Site Evaluation [ ]Improvement Permit&ATC [ ]Both
4. System to Serve: [0iouse [ ]Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People #Bedrooms 3 #Bathrooms Dishwasher[ Garbage Disposal
ashing Machine [1•]'gasement/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: vounty/City [ ]Well [ ]Community ,�
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ]Yes [L]'No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***XfDAEOF THE PROPERTY MUST BE
C, SUBMITTED WITH T i,S APPLICATION.
Property Dimensions: I J , 7 S / C� E" WRITE DIRECTIONS(from V�!ksville)TO PROPERTY:
Tax Office PIN: # -6- -77d O �d f; n� '�'O -b �O U �n
Property Address: Road Name/ne'a✓2 Y ` LOT/ �"pY I�� �� Y1'� 1 .� • b w Q 0 l
City/Zip vL`hV A-y')t. e Z7 0 r--)?-/2 4/1 f�- 13o u�T ;3 tJ X11
If in Subdivision provide information,as follows: �� 'f"' �L� V C L- r
bl
Name: = ,P V 0 k 74 ca els
1. � e
Section: Lot#: ; L
' C 7` A0 A4—
`
This is to certify that the information provided is correct to the best of my knowledge. I unde stand 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. 1, 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 to conduct all testing rocedures as necessary to determine the site suitability.
DATE Z' SIGNATURE w►/v`
Revised DCHD(06-96)
THIS AREA AIAy BE USED FOR bRA1VINC YOUR SITE PLAN:
s.
:E
Gihn
•
OR
t ^,
06 �M
• DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME AY DATE EVALUATED
PROPOSED FACILITY /9V PROPERTY SIZE
SUBDIVISION 0�irof '✓ rr zlC ROAD NAME z6%p / .CSV
Water Supply: On-Site Well Community Public L�
Evaluation By: Auger Boring I Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position .4—
Slope
4—
Slo e%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 5/ r
Texture group
Consistence i
Structure {�
Mineralogy /
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: / OTHER(S)PRESENT:
REMARKS:
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 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-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(O1-90)
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w_Ie , ounty Health Department
U ^� E' nmental Health Section
1 P.O. Box 848
210 Hospital Street
`S Courier# : 0940=06
ENVI pAVSEC� NL1N Mocksville,NC 27028
Phone:(336)- 53-6780 Fax:(336)753-1680
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection �i�� Zh2,
a�
Name: ��J H.l�f �r/x,lJ 6-.4P-- Phone Number-33-1- - 29 R-"7 'Z�Oome)
Mailing Address: fl-,-q 51%14m le.-4, b 70�Z-S:-' -7;L :!�7 7 2 a� ork
1 A&%C, IVC. -Z-'7o v Laf,,.,-.q .fI&njZy&L4K AojeS
Detailed Directions To Site: /ZT. 6, ei"' ,Co f= tY n) Ai..9 4� e) d
�-�✓� v � �� �.�Y <«' `^'-v��... � T )��-� SLl�lw t����' `��t ,z�st/f,�t�S"- �s
Property Address:
Please Fill In The Following Information About The EXISTING Facility: J 7�q L&J
Name System Installed Under: Z o f,.^F' P,,- Type Of Facility: A-cs/b L, w`F-t��---
Date System Installed(Month/Date/Year):57 ?;Z Number Of Bedrooms:— i Number Of People:__
Is The Facility Currently Vacant? Yes If Yes,For How Long?
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:,5 i Z
OW
Type Of Facility: a sv v lrG-- �hmhPr(lf R�irnnma• Number of People
Requested B� �^-�-- /�-2� Date Requested: 3 -1- f ��
(Signature) `
For Environmental Health Office Use Only
Approved V Disapproved
Comments:
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 Cleck` Money Order # 16 Pq Amount:$_ 00.6)Q Date: L31t5h I)
Paid By: +� /? Received By: It
Account#: Invoice#:_ 7117
vi eT
ra.(Act ��