204 Shady Grove Lane Lot 9,; XD
AUTHORI7ATION NO 0 6 3 4 " DAVIE COUNTY HEALTH DEPARTMENT.
Environmental Health Section PROPERTY INFORMATION
Permittee',r P.O: Boz 848
Name. //0A/YS(hnit %• 77 Mocksville;.NC27028 Subdivision Mme: r'ra /Ove'
Phone #: 704-634-8760 >'
Directions to property; /1 l� // f r�✓ Section: / Lot"
AUTHORIZATION FOR.
WASTEWATER. Tax Office PIN:# 7- �04t):,
SYSTEM CONSTRUCTION
—DAL.1—CLIo,J,/1
**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 FomdAuthorization Number should be presented to the. Davie County Building Inspections
i Office when applying for Building Permits.
On compliance with Article 11 of G.S. Chapter 130A, .Wastewater Systems; Section,. 1900 Sewage Treatment and Disposal Systems)
J ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�>d YIJr2TS1J. �'T�.L1f !b ri" / ✓/� �% _ IS VALID FOR A PERIOD OF FIVE YEARS
�. ENVIRONMENTAL HEAL SPECIALIST-` DATE ISSUED
nM ` �:�. �✓ ew�`iw x y., ..y,n:y,t�,z--,:-..xwa �.�y,rt.; r -, W.... V4';y; l} 4q¢E:.r1 ,v;,r�qa4,vk:.i4
DAVIE COUNTY HEALTH DEPARTMENT
2 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
�sy� �.
Per3t4xes
."Subdivision Name
Duec�ions t(? r5perty:' Section: / Lot:
I PROVEMENT����'
f PERMIT Tax Office PIN:#�rF- 4 - c
q%� soadName:��ta(' L, 1~] V;
**NOTE** This Imp ement 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)
` r _ ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r ) �' /'.- %'%. 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 # BEDROOMS�,2 # BATHS �_ # OCCUPANTS GARBAGE DISPOSAL: Yes o Nom
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEBHIFr - # SEATS INDUSTRIALWASTE: Yes or No
7 .LOT SIZE 3/�� TYPE WATER SUPPLY 140 DESIGN WASTEWATER FLOW (GPD) '�6� ,NEW STfE ,REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE A2_GAL. PUMP TANK GAL. TRENCH WIDTH. ROCK DEPTH L LINEAR PT. -f /J
OTHER .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT - —
i
**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) 6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
1
AUTHORIZATION NO. OPERATION PERMIT BY:—DATE:
ell
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I1 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 05/96 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMITL130997
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed IX, `Q -v k Contact Person40A—
/� Gni /' �
Mailing Address �p . 02 n &I Home Phone '7 � g � `T� 9
City/State/Zip Ad rja y, C ce, r,- %r6 ,6 _ Business Phone �
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: ❑ Site Evaluation l—Improvement Permit & ATC
4. System to Serve: 8 House ❑ Mobile Home ❑ Business ❑ Industry
5. If Residence: # People # Bedrooms 3
5'5ishwasher ❑ Garbage Disposal 9—Washing Machine ❑ Basement/Plumbing
6. If Business/Other: Specify type
# Commodes
If Foodservice:
7. Type of water supply:
# Showers
# Seats
9-County/City
# Urinals
❑ Other
# Bathrooms
❑ Basement/No Plumbing
# People # Sinks
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes a -- No
*** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions:
Tax Office PIN: # J` % �g y J� // LL
Property h
Address: Road Name •• C i� f/ -e Iq N2
City/Zip C%
If in Subdivision provide information, as follows:
Name:
Section:
Lot #:
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
'oI S r)6 DEQ
�J// PvS lam• � I Dn U///
Cwt +0 Abi.
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
e kc,-.s'
avie County Health Department to enter upon above described property located in Davie County
and owned by v /ter/ t 13 4 jcA me -/� -�C • to conduct all testing procedures
as necessary to determine the site suitability.
DATE 3 7 SIGNATURE
Revised DCHD (06-96)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION_/LOT'
Soil/Site Evaluation .
APPLICANT'S NAME tS - DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE 3l`fA�
SUBDIVISION ROAD NAME
Water Supply: On -Site Well Community Public f
Evaluation By: Auger Boring Pit '� Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
A—
-
Slo e %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON H DEPTH
f
p
Texture groupG'
Consistence
Structure
i
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
1
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: <
REMARKS:
DCHD (01-90)
EVALUATION BY:
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 1 FP -Flood plain H - Head slope
Texture
S -Sand LS - Loamy sand SL - Sandy loam' L - Loam SI - Silf
SICL - Silty clay loam SIL - Silty loam .. CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
MOW
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