247 Griffith Road Lot 20Ale Y.
AUTHORIZATION NO: Q 9 3 4 DAVIE COUNTY HEALTH DEPARTMENT le
Environmental Health Section PROPERTY INFORMATION
a"Permittee's P.O. Box 848
Name: f �rV Mocksville, NC 27028 Subdivision Name:
r Phone #: 704-634-8760
Directions to property: AUTHORIZATION FOR Section: / Lot: /. A/1
WASTEWATER Tax Office PIN:#��'+�
SYSTEM CONSTRUCTIONj,,
Road Name: 6'1- ifKi 0 t�
**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)
ENVIRONMENTAL HEALTH SPECIALIST
,7—,1— Z2
DATE ISSUED
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
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7
DAVIF�,COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION `
Name: , Subdivision Name: '
Dueohons Lw
to property: .11 :lf� / ; C,
o' ' Section: Lot: J
n1SPROVEMEN'P
PERMIT Tax Office PIN:45w-
Road Name:ti.�ipa',.
**NOTE** This Improvement Permit DOES NOT authorize the constriction or installation of a septic tank system or any wastewater system An�� Y
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained f)DM this Departmentpior to the
constmctiion/installation of a system or the issuance of a building permit
(In compliance with Article 1.1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Ticatment and Disposal. Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGF, YOUR WASTEWATER .
ENVIRONMENTALHEALTft SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BETRE
1 INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE ! 7. # BEDROOMS-- # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
a
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE . # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes- or No
LOT SIZE.A c TYPE WATER SUPPLY Ali /DESIGN WASTEWATER FLOW (GPD) _ BGG NEW SITE .REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE ,&%y GAL. PUMP TANK ' GAL. TRENCH WIDTH .* ROCK DEPTH LINEAR FT. 416
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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) 6348760.
OPERATION PERMIT
t s SY S�INSTALLID BY:
E33'
IS' . .
�pp
AUTHORIZATION NO. �7 V ' OPERATION PERMIT BY:
DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05196 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department 2 2
r Environmental Health Section n is !_5 Q
P.O. Box 848 I J
Mocksville, NC 27028 JUN
J 2 5 1997
M
(704) 634-8760
�
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEt"
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed 13-e a ve N4 m/0
,�Ze%N CD
,(AUC, Contact Person / d /
13 - rse,C fi�f�
Mailing Address 3 40 S /"'C' G
Mg ad
Home Phone _ `7 I >� 4-67
Z
City/State/Zip Aloc ec y • L Cr
jv e 270-e fr—
Business Phone
-7O /
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: �5ite Evaluation [improvement Permit & ATC
4. System to Serve: VIKOuse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
[ ] Both
5. If Residence: # People # Bedrooms_ # Bathrooms Z [ ] Dishwasher [ ] Garbage Disposal
['Washing Machine [ ] Basement/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: [ ] County/City [ Vell [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ No
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** ASF THE PROPERTY MUST BE
y SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 1 �/� WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #d
Property Address: Road Name `
City/Zip .4��e ;
If in Subdivisi 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 County Health Department to enter upon above described property located in Davie County and owned
to conduct testing procedures as necessary to determine the site suitability.
DATE �" �- -5'7 SIGNATURE 2,✓
Revised DCHD (06-96)
THIS AREA MAY $E USED FOR DRAWING YOUR SITE PLAN:
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation p
NAME %��lt/« DATE EVALUATED
3/vh0/
ADDRESS
PROPOSED FACIILTY Zrt!—o
PROPERTY SIZE ' 'I'le ``//
LOCATION OF SITE �O , �l/ Yi ,el
Water Supply: On -Site Well l/ _ Community Public
Evaluation By: Auger Boring Pit I _"' Cut
FACTORS
1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
�
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
Consistence
Structure
.�
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
f
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: OU EVALUATED BY: Z!/�f
LANG -TERM ACCEPTANCE RATE: ly OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R -Ridge S7Shoulder 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- V+:!. -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
DCHD(01-901
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