257 Griffith Road Lot 21. .. :. ,�.. ... '.,_ -:4 �y 1.- .ice �� "'. .. • i .'.. .:_... .. .-.. �.,'. �'-:'
AZJTkiORIZP,XrION NO. 14 3 0 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee'3 P.O. Box 848 { —
Name:, ' lF\\u'-Rls��h�t�-�'�"�C7�p•Mocksville,NC27028 Subdivision Name:
Phone #: 704-634-8760
Directions to property: V�'V f i? Section: Lot:
AUTHORIZATION FOR _
i 6"_'A � ` tJ Y/Atli+►j V Lt_• q � � WASTEWATER Tax Office PIN:#'S &U7
SYSTEM CONSTRUCTION �,
`i'00 t')t r,..i � L (� � t -t ; �� r�L.! Road Name: &Ci (% I Tj4 PX)Zip:t_ C4r)
**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 Fonr/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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRGN?&+'AHEALTH OPECIADATE SSIPED
.a �_�5�'!�^"�?'.roy`;'�'f�`;tyY't,�+'``l�•flA{pu9�+"5: ��r,1 J, �„rr� .:,.. :- •_ �_fa.��,� o ° 'w..,;`�!^,-Y--ti-: rY•--Ii.d T"-f-�a
1434,I)AVEE COUN, HEALTH DEPARTMENT "'
IMPROV NT AND OPERATION PERMITS PROPERTY INFORMATION
�ermiffee's; bs P
t� 1
Named ...�� +8► 1 a KAM$
Subdivision Name.11�It
Directions toro' ' : �;
P PertY�} .Section: Lot:
ff"R0. r}r
VALL. i � ED P&WNT . Tax Office PIN1 53 St / f .
,04 SO .C.4 ulpt 4—V4, , 003 ujc l . Road Name: kill ZiP:2-,?,..,W
**NOTE** Ibis 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 L of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
,r! ***NOTICE*** THIS PERMIT L4SUBJECT TO REVOCATION IF SITE
�.. PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRO _ HEALTH ST DATE SS D SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
_r INSTALLING THE SYSTEM,
,RESIDENTIAL SPECIFICATION: BUILDING TYPE but # BEDROOMS #BATHS Z'#'OCCUPANTS _2- GARBAGE DISPOSAL: Yes + No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFI # SEATS INDUSTRIAL WASTE: Yes or No
/J 'r �(` �, ^
LOT SIZE �/ 'TYPE WATER SUPPLY *" DESIGN WASTEWATER FLOW (GPD) a �J NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE J GAL. PUMP TANK GAL. TRENCH WIDTH 'ROCK DEPTH J Z LINEAR FT.
t OTHER ` Dis.,a fix
REQUIRED SITE MODIFICATIONSXONDITIONS: i Vjj irF I OFF "5'CE i V a e� Dip ��QP j,tA JJ
IMPROVEMENT PERMIT LAYOUT,;
OPERATION PERMIT
SYSTEM INSTALLED BY: _
.. :. , � •moi.,
n
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 I L 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.
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMITR M R 0 U N
`}} T Ir Davie County Health Department
l�� Environmental Health Section 10
V �y 6
P. O. Box 848
R1'wil
Mocksville NC 27028
V(368 W76 0
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be BilledEContact Person 1 h pn'1
Mailing Address 3n:S O 1 I I m li N IN Home Phone Jgo0 — y d j 0_
City/State/Zip 1L %//e C d 90ao Business Phone
2. Name on Permit/ATC if Different than Above 5 Iq Al e
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
Dishwasher
❑ Site Evaluation
a House ❑ Mobile Home
# People 12
❑ Garbage Disposal
6. If Business/Other:
# Commodes
If Foodservice:
7. Type of water supply:
Specify type
# Showers
City/State/Zip
a' Im/provement Permit & ATC ❑ Both
❑ Business ❑ Industry
# Bedrooms 3
Washing Machine ❑ Basement/Plumbing
# Urinals
❑ Other
# Bathrooms
Q—$Tement/No Plumbing
# People # Sinks
# Seats Estimated Water Usage (galloons per day)
❑ County/City Lid" Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes a— ,
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A HL)AT" THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: —P l9q -4� X h bD S H SU X q-c&-� 1
Tax Office PIN: # t 1
1
Property Address: Road Name 1
^ '1 1
J` 1
City/Zip v 1
CO
1
If in SubdiviE
ion provide information, as follows: 1
Name: lie. 1Q2QnJ �' I 1 S 1
C�1 1
Section: Lot #: 1
1
1
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
-qo + D
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 ro>��, 7n to conduct all testing procedures
as necessary todetermine the site suitability.
DATES— In
SIGN
Revised DCHD (06-96)
YOU MAY USE THE BACK OF THIS FORM FOR PRAWING YOUR SITE PLAN.
DAVIE COUNTY HEALTH DEPARTMENT
..i Environmental Health Section
Soil/Site Evaluation
C
NAME �/y S DATE EVALUATED----����
ADDRESS PROPERTY SIZE
/A.//¢`L�f J n
PROPOSED FACIILTY �YSC LOCATION OF SITE
Water Supply:
On -Site Well �'
_ Community
Public
Evaluation By:
Auger Boring
Pit L_�
Cut
Texture group
Consistence
FACTORS
1 2 3 4
Landscape position
4 L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
" "G a
Texture group
Consistence
Z4l�
Structure
Mineralogy
-r
HORIZON III DEPTH
_77
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: Y�
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY:
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- 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
Mi neralosy
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