167 Shady Grove Lane Lot 17w'AUTHOAI2.ATION NO.
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12 2 4 DAVIE COUNTY HEALTH
. DEPARTMENT
.,..:.- .,
Environmental Health Section
PROPERTY INFORMATION
Permittee s t
P.O: Boit $48
Name..
O v Mocksville, NC 27028 `.
Subdivision Name:
Dtirections to property.
Phone #-.:7,04-634-8760,.:
✓GSection
Lot:
.. AUTHORIZATION FORWASTEWATER
Office
SYSTEM CONSTRUCTION:.
Tax PIN-.#
RoadNamei' iQ�L r0�ip:: d0(p`:
L**NO,�E*.�, This Authorization for Wastewater System Construction MUST, BE ISSUED by the Davie County Environmental Health Section prior'
to'jssuance of any Building Petmits.:This Forrn/Authorization.Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
ompliance with Article 11 of G.S. Chapter.I30A, Wastewater Systems;Section:1900 Sewage Treatment andDisposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALD) FOR APE OF FIVE YEARS.
ENVIItONMENTAL HEAL H SPECIALIST. . ,DATE ISSUED
2 2 4 DAME COUNTY HEALTH DEPARTMENT,
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
-'_Pe' riaft - — -
AA bositu S Subdivision Name: GO'
lYiectio`ns3opropeaty: y 4QV& Section: �J Lot:
�.� IMPROVEMENT
PERMIT Tax Office PIN:4tt,
Road Name—i a. d b rov4ip: -00�a
i
**NOTE**..Tbis Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system.'An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
constructiordinstallation of a system or the issuance of a building permit.
\ (In compliance witti Article 11 of G.S. Chapter 130A, Wastewater Systems, Secdon .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IFSITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM. -
RESIDENTIAL SPECIFICATION: BUILDING TYPE _-Zl— # BEDROOMS -y # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No ,, ,
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT / # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �(% NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /kd GAL. PUMP TANK GAL. TRENCH WIDTH S ROCK DEPTH LINEAR FT.
OTHER
**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) 634-8760.
OPERATION PERMIT ,, Akm p
SYSTEM INSTALLED BY: IL/ //J/ 7zu
-",
ID
2�-
�y 57ow,
AUTHORIZATION NO. Yom— OPERATION PERMITBY:DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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.
DCHD 0996 (Revised)
11 i
APPLICATION FOR SITE EVALUATIOMMPROVEMENT I
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704)634-8760
****IMPORTANT****
ATC
THIS APPLICATION CANNOT BE PROCESSED I
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed�Contact Person hep l� �icznG
Mailing Address `f/7 Home Phone'
City/State/Zip /�%�moiCs✓�L�e /f/CBusiness Phone
2. Name on Permit/ATC if Different than Above m e
Mailing Address^2iri t City/State/Zip
3. Application For: [ ] Site Evaluation pj Improvement Permit & ATC JWBoth
4. System to Serve: p(] House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms # Bathrooms;Z -:�L N Dishwasher [ ] Garbage Disposal
p(j Washing Machine ffBasement/Plumbing [ ] Basement/No Plumbing
6. If Business/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
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes DJ No
If yes, what type?
I _
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***X&� OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 9/0 %Y 16-d,19XgZ 640 X 90a.3S; WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: ` #� 70Q / T a .t, h a a TX'
Property Address: Road A9i� s
City/Zip %/�i�a P /L`/ G ; O/i c 1.Z o- C,
If in Subdivision provide information, as follows: i o F S�i cz
Name:�c✓e/aome-o j> 4.19 v v Z rr7—
e
,
Section: Lot 4h
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. I, also, understand that I 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 n ,�duct all testirfg)�i to determi9efhersite suitability.
Revised DCHD (06-96) /
THIS ARTA MAY SE USED FOR DRAWING YOUR SITE PLAN:.
v v
^ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section��
Soil/Site Evaluation DDD
NAME 4
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
ISK�7,1i � (r1i (4�11[ll
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit_ Cut
pf�
FACTORS
1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
A- 369" '
Texture group
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
�t
SITE CLASSIFICATION:
G�
EVALUATED BY: '& Z
LANG -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 -:lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
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 CR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineraloey
1:1, 2:i, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolile - 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