849 Gladstone Road Lot 6t4l)*z3 .
+ �A%Ho ATION NO: Q 8 2 2 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION.
ernmttee s
' ! PP.O. Boz 848
Name: "}� (,n;� �Z[6 f� Mocksville NC 27028 Subdivision Name , �/��tao
/ Phone 4h 704-634-8760 .
Directions to property: �////1 f io. .r Section: Lot: .
AUTHORIZATION FOR
WASTEWATER Tax Ofa
s PIN:#
SYSTEM CONSTRUCTION- �
m� (T/QC1S /Oil log
�.
**NOTE** This Authorizatiion 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, Sect ion :1900. Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION " IS VALIDFORA PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH 'ECIALIST.,', DATE ISSUED
y y _..rz.,r••a v x.ryt .,'�(Y'.,"�'i4 y'SnYY4"..`ytTS;rtlXr'l'�n {Ia.ri..,iML'"'N4.y •�i,.n'1•:rv•s tr<`"14i:n:i
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permattei�.I , . ,
Namg r (1t7%gY&f is _ Subdivision Namj.
e
Directions to property: f ,; •%r %e ,. Section: Y' % Lot:
G•
i IMPROVEMENT
( PERMIT Tax Office PIN:#
l ` Road l am : rI L(CL��/L'77 p ' C7 4
**NOTE** This Improvement Permit DOES NOT authorize the construction or - tallation o septic tank system or any wastewater system. An
AUTHORIZATION, FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constnictionlinstalladon of a system or the issuance of a buildd ypmg permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Spt�nw section .1900 Sewage Treatment and Disposal Systems) ,
f t, s, :/IG i ***NOTICE*** TIIIS PERMIT IS SUBJECT TO REVOCATION IF SLTE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED x SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE:
INSTALLING THE SYSTEM.
. RESIDENTIAL SPECIFICATION: BUILDING TYPE i%' ':# BEDROOMS_ # BATHS >;i- # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE - # PEOPLE # PEOPLE/SHIFT # SEATS _ INDUSTRIA[. WASTE: Yes or No
LOTSIZE-4� TYPE WATER SUPPLY 4 -'DESIGN WASTEWATER FLOW (GPD) *7 y NEwsrrE REPAntsrrE
p
SYSTEM SPECIFICATIONS: TANK SIZE , oi) GAL. PUMP TANK -GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. �L
OTHER
REQUIRED SITE MODIFICATIONS/CONDTTmNS:
IMPROVEMENT PERMIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:307 9:30 A.M. OR 1:00 - 1:30P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 6348760.
OPERATION PERMIT �%. .O J ,AI
- -SYSTEM INSTALLED BY:
,4O /8 �x zco t�
io' zs'
s
T
(P�
1
,.�q� �
AUTHORIZATION NO. OM OPERATIONP yov s c
BY: day- �'A"-'P DATE: 0 I
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED A13OVE 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 AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
DATE �' SIGNAt E
(< r
CO SENT FOR SITE EVALUATION TO BE DONEON ABOVE DESCRIBED PROPERTY
MUST CHECK QNE:❑ 1. I OWN the property. ❑ 2. 1 D6 N T OWN the p
If you checked Box #2, the rest of this form MUST be completed by the owner or a'person authorized by the'owner
hereby give consent to the authorized representative of the Davie County Health Department to enter upon above de
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 In
^'and disposal system.
DATE SIGNATURE
rDCHD (1re3) _ ...
• DAVIE COUNTY HEALTH DEPARTMENTY
Environmental Health Section
/ Soil/Site Evaluation
NAME 1 %6 �.C/ /✓ DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE �✓����>TX/P
Water Supply: On -Site Well - 'Community Public
Evaluation By: Auger Boring - Pit C/ Cut
FACTORS
12 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texturegroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH
�! +
Texture group
Consistence
Structure
S' .k
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
:f
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
it
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY: a /
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
tron slsrCn ce
Moist - ..
VFR-Very friable FR -Friable, FI -Film 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-Subangularblocky 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(provisionallysuitable), U(unsuitable)
LTAR - Long-term acceptance rate -'gal/day/ft2
DCHD (01-901