875 Gladstone Road Lot 12t ,,,,.dATION NO: 090'5 '- DAVIE COUNTY HEALTH DEPARTMENT
P�r + Environmental Health Section
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PROPERTY INFORMATION
w4tttttee s ^ P.O. Box 848
'-.Name: �jji.h6 Mocksville; NC 27028 Subdivision Name: a,n.✓i/o nl�r
Phone #: 704-634-8760 y
Directions to property: I i Section: Lot:
AUTHORIZATION FOR
WASTEWATER IN:# Office
SYSTEM CONSTRUCTION Tax �%-
RoadNaYne:Qa4:1 hap— :Agg
**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 I30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION:
IS VALID FOR A PERIOD OF FIVE YEARS
ENVIRONMENTAL HEALTH SPECIALIST DAitATs§UED
DAME COUNTY HEV,AryAM �y, ,r �t1•-�^t' , w�4,Mr/,. �,..� ,..,..,._ , w ,...,. � . , 4 ..
°> 1 `- •- LTH. DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
PervVeets'-
Name%r in ,6 Subdivision Name:
Dlkct o} s to property: r Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road& e: n r161Z41' -&4:'
**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.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
n ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
+[1M p di ? (1114,11 PLANS Olt THE INTENDED USE CHANGE. YOUR WASTEWATER
ESYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST .DATE ISSUED
INSTALLING THE SYSTFAL
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 'a # BATHS 2- #OCCUPANTS —GARBAGE DISPOSAL: Yes oc Uo
COMMERC
rI
AAL �S�PEECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ^� TYPE WATER SUPPLY CQ DESIGN WASTEWATER FLOW (GPD) too : NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE��oGAL. PUMP TANK GAL. TRENCH WIDTH ) ROCK DEPTH /z LINEAR Fr.�`'��
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THER Dy-,4AWP-JOP
REQUIRED SITE MODIFICATIONS/CONDMONS:
IMPROVEMENT PERMIT LAYOUT
**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) 634-9760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
%2
AUTHORIZATION NO. � OPERATION PERMIT BY: DATE: + /
"THE ISSUANCE OF THIS OPERATION PERMrr SHALL INDICATE THAT THE 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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -
DCmm 05/96 (Revised).
t"
ICATION FOR SITE EVA bATIONAMPROVEMENTS PERMIT
•
Davie County Health Department ,
Environmental Health Section
P. Box 665
+
Mocksvilille; NC 27028
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Home Phone
Business Phone�o
Above --,.;-
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0 General Evaluation 0 Septic Tank Installation Permit
House
❑ Mobile Home
❑ Place of Public Asser
❑ Industry
' p+c ❑ Other
❑ Unknown
on":1
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.
Section Lot #
,-
❑ Basementnumbing".
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation .
NAME iJr✓ DATE EVALUATE])
ADDRESS PROPERTY SIZE -Al
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On -Site Well - Community Public /---'
Evaluation By: Auger Boring Pit ✓ - cut.
FACTORS1
2 3 4
Landscape position
Slope %
HORIZON.I DEPTH
-
Texture group
2Af'L
Consistence
Structure
Mineralogy
HORIZON II DEPTH
'1O
Texture group
Consistence
Structure
b
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
G
SITE CLASSIFICATION: �� EVALUATED BY:
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
- CAN SiSTRNCR -
Moist _
VFR-Very 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 - -
SC -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