286 White Dove Way Lot 9AUTAORDiATION NQ '18 it 3 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's�, P.O. Box 848
N m Subdivision Name: Ot tic V
a e: Mocksville, NC 27028
Phone # 336-751-8760
Directions to property: -10 (�20 1 Jc- Section: Lot:
AUTHORIZATION FOR
eAj 7— WASTEWATER
L -6-)r' WAY �-ur Tax Office PIN:# �S�20 6-q - "I q �Ro
SYSTEM CONSTRUCTION
1p:
—�T R d Pame: L z -
**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 applyinArfor Building Permits.
(Incompliance7ith Article I I f S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
)4- YEARS.
IS VALID FOR A PERIOD OF FIVE
ENVIRO HE�LTH SOECIA DATE MUD'
7 .77
4 �DA HEALTH DEPARTMENT'
VIE
JMVROV
. . . . . . . . FAWNT AND OPERATION PERMITS PROPERTY INFORMATION
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Subdivision Naine:
7.
Dir�ptii)nsjoproperty, ection:
!.S. Lot.
PERNW,.
Tax, W
PIN:#
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NQTE** Thislrfipr�yerhent Pennit DOtS NOT, authofize die consftuction or iristallation of a septic. tank system or any wastewater systeni An,.
.'AUTHORIZATION FORVASTEWATERSYSTEMCONST ' RUC11ON must be.obtained frorn,this Departinent pfior to the
6ons&uction/ingtallation of a'syitqrn or the issuance of, a building,pernut.
0�lcqrnpliance widt Article 116? 'G S. Oipt�r,00A; Wastewa'ter System,. Section. 1900,Sewage Treatnient and Disposal System)
PLANS 0 THE USE.CHANGE. YOUR WASTEWATER
'§PF '11M, CONTRACrOR WSTSEEINIS PERrvff BMRE
'EN T14 bAJW, bXTT 1A SYS
INSTALLING THE SYSTENL'�
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS #BATHS # OCCUPANTS GARBAGE DISPOS Y No
COMMERCIAL. SPECIFICATION:. FACILITY TYPE # PEOPLE # PEOPLE/SHIFT SEATS INDUSTRIAL WASTE: Yes or No
LOT -SUE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD, NEW SHE REPAIR SITE
81ZE ROCK DEPTH 12' LINEAR Fr.
SYSTEM S P'ECIFICATIONS: TANK iQ�&L. PUMP TANK ----GAL. TRENCH WIDTH
'OTHER S
kQUIJiED 811tMODIFICATIONS/CONDITI ks:jd LL. V..) doov)roaz --to' D AC C
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.!*CONTACT A REPRESENTATPvT OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
4 BETWEEN 8:30 - 9:3.0 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-816.0.
JTW_PblrM L)=NtKWkW ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARn.CLg 11 OF G'S' CHAPTER 130A, SECTION - 1900 'SEWAGE TREATMENT AND DISPOSAL SY I STEMS', BUT SHALL IN AKEN AS
NO WAY BE T A
GUARANTEE THAT THE SYSTEM WELL FUNCITON
SATISFACrORILY FOR ANY GIVEN PERIOD OFITI�ffi.
DM 05M (R"iwd)'
APPUCA11110N FOR SIX EVALUAHON/IMPROVEMENF PERMI1 & ATC
Davie County Health Deparftnent
En vironmenfal Health Sixftn
P.O. Box 848/210 Hospital Street
Mockaville, NC 27028
(336) 751-8760
Id - /y, -�? F/
***3111P0RTANT*** THIS APPLIChTIOX CUMOr BE PROCESS= UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
Nano to be Billed.
Contact Person - 15;+)— 14 4 -/,L -
Mailing Address.
Ham Phone �-9 2 -5- 5 4 f-
City/State/ZIP
Business Phone 4rl
2.
Name on Permit/ATC
If Different than Above
Mailing Address
#a -/Y. city/st-ate/zip 54---)-r 7scAj-), VC -Z--Ieg I
3.
Application For:
U Site Rvaluation
0 UVrovement Permit/ATC XBoth
4.
System to Service:
A House 0 Mobile
Home 0 Business 0 Industry 0 Other
a.
If Residence:
People
# Bedrooms # Bathrooms
ADishwasheir
Garbage Disposal Washing Machine Basement/Plumbing 0 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. IV" of water supply: 0 County/City '4 Well 0 Commmity
9. Do you anticipate additions or expansions of the facility this system is Intended to serve? 0 Yes ((N o
If yes, what type?
***IKPOR7ANT%** CLIENTS AtUSTCOMPLETE THE REQUIRE0 PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMIZTED by the client with THIS APPLICATION.
Property Dimensions: 57 4-C ..
Tax Office PIN: # NZ ouT�
Property Address: Road Name �OoE7 "4t,
City/Zip /1106le5 1,111-tei A/C- Z-7,'L�J'
If in a Subdivision provide information, as follows:
Name: JL)o I T(5' 7D o () /J-c� R (5�&
Section: Block: Lot: 17
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
4101 41010-77f -7-b
-DOL/c ,-4-, '?o,2,o?t�x7,-1 -5
PlcJ ALT 13eJ:-,o1LC- 121o,-Or�,)
Date Property Flagged: 12, — /3— — � �c)
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter sire subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted In this application is falsified or change& 1, aLw, und"and that I am responsiblefor all charges incurredfrom
this appfication. 1, 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 SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (include all of the following: Existing and proposed
property lines and dimensions, ' structures, setbacks, and septic locations).
0
QS
Revised DICHW(07/98)
P N-) E0 0 0( --
Account No. 3LI
Invoice No. 3 Ye�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION- LOT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE 6P - 5 /A C-16
SUBDIVISION
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring Pit —
ROAD NAME J,)j�hjCiWL27 WA
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
Slope %
HORIZON I DEPTH
0 "Jo
Texture group
SC -L -
Consistence
PrSSS
Structure
Mineralogy
HORIZON II DEPTH
/P - IL4
"A -710
Texture group
Consistence
r -
Structure
<
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
6V
Mineralogy
HORIZON IV DEPTH
.3U4
i4o f
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: 0
REMARKS:
DCHD(Ol-90)
LEGEND
LandscaDe Position
EVALUATION BY: 5;jt�;� _E)0jA0CA_14
OTHER(S) PRESENT:
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
No
No
No
No
No
No
no
ME
no
ME
on
No
on
No
so
ME
ON
ME
no
no
ONEMENUMMENNEUMMINEEN MEMNON MENNEERNMEMENUMMENNE
OMEONE MEMNON MErIMMMUMMEMEMUMMEMEM NOREEN MEMNON
ROEMER
MENNEN
RENNER
MENNEN
ROEMER
MEMMEN
REESER
RENNER
EMMMEM
RENNER
EMEMME
MEMNON
EMENSIM
Smomwill
PIENEEM
MENNEN
WERNER
�.Ilmmmmm
MEMNON
ROEMER
RENNER
MOMMEM
MENNEN
MENNEN
RENNER
REESER
MEMEME
MENNEN
EMMEME
MEMENE
MEMNON
MEMEME
0