173 Sand Pit Road Lot 27AUTHORIZATION NO: 0 6 15 DAVIE COUNTY HEALTH DEPARTMENT - - 2AA
4 Environmental Health Section PROPERTY INFORMATION
Permittee�'s'��✓ } P.O. Box 848
Name:–�4�'' Mocksville NC 27028 Subdivision Name:l
Phone #: 704-634-8760
Directions to property:1.. ,/ f4111 Section: Lot: _
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name:–:5lq/✓b prr zip
'a7
-
7-1 �O
**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{r ` � �;, f f � ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r > }//, IS VALID FOR A PE OD OFARSO �a
ENVIRONMENTAL HE k] STH SPECIALIST DATE ISSUED �•
i 'yn`Irs�Y�Fs"Z"� .yvq;�•,. '+r .., a .. ` 's%..d - rp.lkf
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFO TION
�� 1 'P
NaFne.• Subdivision Name: give -
Directions to -property. ,els�Section: Lot. ;
t' IMPROVEMENT
;EMIT Tax Office PIN:#Qfo 1�
Road Name: L'<Ata pnt1 rs�
**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.& Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
' frA
***NOTICE"* TEAS PERMIT IS SUBJECT TO REVOCATION IF SITE
yd,r ? r ` - " PLANS OR THE INITMED.0 i CHANGE. .OUR W TER
CONTRA
ENVIRONMENTAL SPECIALIST , DATE ISSUED SYSTEM CTOR MUST BEFO
L INSTALLING THE SYSTEM.
RESIDENTIAL; SPECIFICATION: BUILDING TYPE # BIDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION:. FACILITY TYPE # PEOPLE # PEOPLE/SHIFTv V . # SEATS
INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) Q_ NEW. srTL—REPAIR SITE
SYSTEM SPECIFICATIONS: TANI{ SIZE_GAL. PUMP TANK GAL. TRENCH W1DTFi� ROCK DEPTHf$ LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONSICONDITIONS:
�i
IMPROVEMENT PERMIT LAYOUT. l�
IA -1 V CP
00
• r II i
• i�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT POR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30.A.M. OR 1:00 - 1:30 P.M. INSTALLATION. TELEPHONE # IS (704) 634-8760.
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS DLJ "m
L THE REQUIRED INFORMATION IS PROVIDED. /
1. Name to be Billed &2Z�647-- .` ���/c iT6N yi e_ Contact Person �.��/,1.�GL
Mailing Address Home Phone
City/State/Zip Aga ✓AA/t.e �C— 2?��o Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
Sir Dishwasher
❑ Site Evaluation
Cd/ House ❑ Mobile Home
# People
W Garbage Disposal
6. If Business/Other:
# Commodes
If Foodservice:
7. Type of water supply:
Specify type
# Showers
;'ISatelZip-
ImPtrovement Permit & ATC
❑ Business ❑ Industry
# Bedrooms
Washing Machine Q' Basement/Plumbing
# Urinals
❑ Both
❑ Other
# Bathrooms 2 /f
❑ Basement/No Plumbing
# People # Sinks
# Seats Estimated Water Usage (gallons per day)
❑ County/City 2(/Well
# Water Coolers
❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ElYes �d No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Tax Office PIN: # .3 - � 6 - � � 1
1
Property Address: Road Name 1�4NO /.-?Z 1
1
1
City/Zip 1
1
If in Subdivision provide information, as follows: 1
- � 1
Name: 119:Re �%I '
1
'
Section: Lot #: Z7 1
1
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 ownedby� to conduct all testing procedures
as necessary to determine the site suitability.
DATE / 6 SIGNATURE
Revised DCHD (06-96)
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ti 2.208 Ac.
to
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ON
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19-109 22 s��b 2.515 AC. I �� l o� �.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME S/j11'7/�
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED =
PROPERTY SIZE
LOCATION OF SITE
Community
Public
Evaluation By: Auger Boring Pit �'' Cut
FACTORS
1
2 3 4
Landscapeposition_____
4—
—Slo
e Z
Slope
HORIZON I DEPTH
Texture groupRC1-
tGL
Consistence
Structure
Mineralogy
HORIZON II DEPTH
�{6r
Texture groupC
Consistence
Structure
L
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: y� OTHER(S) PRES"T:
REMARKS:
DCHD(01-901
l
END
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
T...rt.,...
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- Ve-y 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