267 Griffith Road Lot 22f " t .r`""7'r"L` '�y � ---�..'Vy�y/'+,'��•' r-..lv....•.nn-- .-«.�; - ,- - �., ..�-.'.f\l...""T,c�•+
DAME OUNTY HEALTH;DEPARTMENT
F� ' ' i1VIPR0 MENT AND OPERATION PERMITS. PROPERTY INFORMATION:. .
Name Subdivision Name:
Dlirections to property. r ,` Section Lot:
]MPROVFMENT
f PERMIT. 'Tax Office -PIN: -
Road,Name: p
*NOTE**: Tbis, Improvement Pb;m t. DOES NOT authorize the construction or installation of a septic tank.system or any.wastewater.sgstem.. An
AUTHORIZATION: FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Depamnent prior to the
r Y consmw ion/installation of a system or;the•is'suance of a building permit
(In compliance with Article 1 l of G:S. Chapter 330A; Wastewater Systems,'Section .1900 Sewage Treatment and Disposal Systems)
lq .�
NOTICE!** TEAS PERMIT.:LS SUBJECT TO REVOCATION IF SITE'
>y u, ,� '
PLANS OR TIRE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRO AL HEALTH,SPEC DATE ISSUED • SYSTEM CONTRACT OR MUST SEE THIS rERMTP EEFOIZE. '
t ; € INSTALLING DIE SYSTEM.
t '; , 1 , ., 4 !�•. . J' it i 'i .' ....r � ... ''-., - .
RESIDENTIAL SPECIFICATION BUILDING TYPE_ , # BEDROOMS #BATHS _yam #OCCUPANTS _� GARBAGE DISPOSAL: Yes or No
COMMERCIAL' SPECIFICATION:,. FACILITY TYPE- # PEOPLE # PEOPLE/SHIFT # SEATSINDUSTRIAL WASTE: Yes or No
LOT S i TYPE WATER SUPPLY DESIGN WASTEWATER FLOW'(GPD) NEW SITE � REPAIR Sri'E
SYSTEM SPECIFICATIONS: 'TANK SIZE GAL•... PUMP TANK . •GAL... TRENCH WIDTH 'ROCK DEPTH LINEAR FT._�
OTHER ;O�G�! ,�f r u Q 1 •lf/l�' l !/ i j`/� r f� /'/1
REQUIRED SITE MODIFICATIONSICONDITIONS. '
IMPROVEMENT PERMIT LAYOUT
A.
a
*'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 (336)751-8760.
r
ts
A 19
UThoRIZATION NO: � DAVIE C OUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P6ndittee's 4 !P.O. Box 848 ','', ' ,
Name: �r !!f?t` rel"' Mocksville,NC 27028 Subdivision Name:
Phone # 336-751-8760 d
Directions to property: ,��/, ' i�• '/ Section: Lot: 0.
AUTHORIZATION FOR ,r
WASTEWATER Tax Office PIN:#�t ''t- - -'
SYSTEM CONSTRUCTION
Road Name: s* I p:
**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 l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�.- �;�r"� :,•,_ , ;;,,, �.f.r t/ t / ,��;,� /� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
J i J
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
< Q
Environmental Health Section
a P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By I I M t�ES; c2
Mailing Address 2oS C2G-e:rSc�Cb GT. Home Phone Ot.) X44-,�-i;44
(,�„�sco�-Sack rJc Z-lloj Business Phone C91a) 7y1-osrz
1
2. Name on Permit if Different than Above
3. Application for: 131 General Evaluation WrSelbffdTank Installation Permit
4. System to Serve: R House ' �� D❑ Mobile Home ❑ Place of Public Assembly
ElBusiness ElIndustry I �' L7 Other ElUnknown R�
5. If house, mobile home: Subdivision Section Lot #
No. of People
S
No. of Bedrooms `t
No. of Bathrooms 3
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: ❑ Public
No. of Sinks
No. of Urinals
No. of Water Coolers
_ Water Usage Figures
❑ Private
8. Property Dimensions 220 x a Sewage Disposal Contractor
® Basement/Plumbing
❑ Basement/No Plumbing
® Washing Machine
® Dishwasher
® Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
❑ Community
'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: PROPERTY INFORMATION REQUIRED:
Tax Office PIN:
f"WH Sol 4-. `A.D" Q4uLZ-'1 12-b. „/1s ] PROPERTY AbbRESS, as follows: -%
Ce, FhTH RD "tKtx) LU--ro#J �`7 Road Name:-'$ --�tQc4 i:l'/,; 7' k
City: NC
SUBMIT A PLAT WITH THIS APPLICATION.
�R_evvissions �elfffeective October 1, 1995.
�- 'qua g
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
3 -z55 --9c: Y=5 ;2, i? -z
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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 procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (193)
,P)
1LS � va.n/l . •ate �
M.Rawtlw•��ilr - _ -
awar
}
f
2.208 Ac.
,26
� i-;892 Ac
25 �
po ,spa""2.897 A te`
M �.p,st 2fa.ts- ~ s Y xT�o•t 39.,r
x a�"rt ne.•s' � _ � s a-or�c�t
—14
EBF
?.627 Ac.
2.515 AC. 1 3.436 Ac.R � ;i
2.105 Ac. -9.109
i09 { m/+ `�°
*�Jt via �I � I• � � �)��'•r f `�
a o
i a o r•w i � .t
Ao
�1 � O � •j � I 2rn ', '� /A� I
q2l u: ,xi.aT
Fd } S.R. X 1453•
- _
Neild
.0a
Gr
Fl f �
I
�b
}
f
2.208 Ac.
,26
� i-;892 Ac
25 �
po ,spa""2.897 A te`
M �.p,st 2fa.ts- ~ s Y xT�o•t 39.,r
x a�"rt ne.•s' � _ � s a-or�c�t
—14
EBF
?.627 Ac.
2.515 AC. 1 3.436 Ac.R � ;i
2.105 Ac. -9.109
i09 { m/+ `�°
*�Jt via �I � I• � � �)��'•r f `�
a o
i a o r•w i � .t
Ao
�1 � O � •j � I 2rn ', '� /A� I
q2l u: ,xi.aT
Fd } S.R. X 1453•
- _
Neild
.0a
Gr
Fl f �
I
DAVIE COUNTY HEALTH DEPARTMENT
.. Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY �' e-�Z
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring Pit c-'� Cut
FACTORS
1
2 3 4
Landscapeposition_____
y
G
Sloe Z
HORIZON I DEPTH
�/
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
{
t''
Texture group
Consistence
Structure
Mineralogy
, •l
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: ILV 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 ;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