199 White Dove Way Lot 7.. ...;fir .,. t ; •
,
AUTHO TION NO: `�
DAVIE C UNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
_.
PermitteP's
'rite
/
120
P.O. Box 848
Name:
Mocksville, NC 27028 Subdivision Name:
Directions to property:
3'
+' � "
/
� !f Phone # 336-751-8760 Section: / Lot:
,k112
J
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#J7-�) 6 a"� - "u
SYSTEM CONSTRUCTION
Road Name &'"� " J4�G Zip. 'A
**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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
' DAVIE OUNTY HEALTH DEPARTMENT_
iMPRO MENT AND OPERATION PERMITS 'PROPERTY INFORMATION
IV`me r� Subdivision Name.
Duectioiisto' ro nt" dt 4 # Section. Lot:
P PertY
IMPROVEMENT.
;ter i , PERMTT . Tax Office PIN:#_A44-
Road Name } Z
**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
eonstruWoMr stallation of a system or the issuance of a'building permit
(Incompliance with Article 11 of G S. Chapter 130A;•Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems) `
PIPLAN OR THE EMMED USE CHANGE. YOUR WAS'T'EWATER
ENVIItONMENTAL,HEALTH SPEMAI IST DATE:ISSUED SYSTEM CONTRACTOR MUST SEE TEAS PERMIT BEFORE.
_:INSALIJ1G THE SYSTEM.
'RESIDENTIAL SPECIFICATION: BUILDING TYPE 'Jilt # BEDROOMS # BATHS,_ #OCCUPANTS_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT ' # SEATS INDUSTRIAL WASTE: Yes or No
LAT SIZE* TYPE WATER SUPPLY (!. DESIGN WASTEWATER FLOW (GPD) f/o w� NEW SITE REPAIR SITE
SYSTEM, SPECIFICATIONS: TANK SIU/�O GAL , PUMP TANK GAL:., TRENCH WIDTH IV • f ROCK DEPTH � LINEAR FT. 57
OTHER
REQUIRED SITE MODIRCATIONS/CONDMONS: '
!".CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL. -INSPECTION OF THIS.SYSTEI41
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (3317751-8766.
APPUCATION FOR SITE EVALUATION/IMPROVEMENIr PERMI 'IT R
Davie County Health Department
Environmenta/Health Section AM 8 Igo
P.O. Box 846/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760 04VIRONMENT&HEALTH
***.ZMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed ✓10 M R P-14 L(— Contact Person '71 r- -y' x N4 -cam
x -
Mailing Address I fl 1C Z Y" Home Phone �/ 5� -7 U
City/State/ZIP /" 0 qk5 ✓/LLC ,(/�- Z-7OZ&-, Business Phone ¢q2--
2. Name on Permit/ATC if Different than -Above /3 2A
Mailing Address 3 / 6,'o4 olu City/State/Zip __j��(//l' w i✓G Z7�r�
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC >K:�Roth
4. system to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. LIff Residence: # People `T # Bedrooms � # Bathrooms
H Dishwasher Ik[Garbage Disposal )lashing Machine Basement/Plumbing U Basement/No Plumbing
6. If Business/Industry/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 ❑ Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes /V—P16
If yes, what type?
***IMPORTANT"** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN hIUST BE SUBAtMED by the client with THIS APPLICATION.
Property Dimensions: 1- r 4C
Tax Office PIN: # S-92,0 -4 � — 1 X90
Property Address: Road Name I,JA ( Ti 7m Vb '-�7
City/Zip /40cr-S✓!LLe , �✓�-
If in a Subdivision provide information, as follows:
Name: W4l115- ), t) ✓e, 4j— P—e� btj)
Section: Block: Lot: -7
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
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. 1, also, understand that 1 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
to conduct all testing procedures as necessary to determine the site suitability.
DATE �J �J " �� SIGNATURE_
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
Revised DCHD (07/98)
Account No.
Invoice No.
b
TRIS MAP I
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2
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2
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A CERTIFIED SURVEY AND NO RELIANCE MAY BE PLACED IN ITS ACCURACY.
i
J
DAVIE COUNTY HEALTH DEPARTMENT
FACTORS
1 2 3 1 4 5 6 7
Environmental Health Section
SECTION_ LOT -7
Sloe %
Soil/Site Evaluation
Texture group
Consistence
APPLICANT'S NAME
�Lr/
DATE EVALUATED
PROPOSED FACILITY
7' '`
PROPERTY SIZE
. J
SUBDIVISION
lil�d/�%�L 'A BLJe
ROAD NAME eaz"R�'
Gy
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring
�Pit
Cut
Structure
Mineralogy
FACTORS
1 2 3 1 4 5 6 7
Landscape position
,L ,L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
7' '`
Texture group
� G
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
LONG-TERM ACCEPTANCE RATE I
, <
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: Z4
REMARKS:
DCHD (01-90)
EVALUATION BY: L J
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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
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
DAVIE COUNTY HEALTH DEPARTMENT"r
Environmental Health Section
Soil/Site Evaluation
NAME &I
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE _ _ Y� p8v`e_
Community
Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L
Sloe Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure l it
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
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-got
EVALUATED BY:lZ
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- Vl---y friable FR -Friable FI -Finn 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 neraloey
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
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