210 Sheffield Farms Trail Lot 16AUTHORIZATION NO. ``, 1352 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's 1 �� 410 1 P.O. Box.848 " r
Name. )w S:eS� tJe+nl".1 Mocksville NC27028 r Subdivision Name: Na( -ILL -0 UCS <M
t(`1 Phone#:704=634-8760
Directions toproperty: )�tJ�(IGC{fA)'t17 Section: Lot. �tD
nn - e�i�*�5 AUTHORIZATION FOR
}It'af! Ii
00 . �ic�iaT OJ yt WASTEWATER cJ Cyt
C� SYSTEM CONSTRUCTION ' TaxOffice PIN:#'1.6�
6
1i�lFrCtf��[tQ+� +� J001(01'.04.Cf,kd iYtocltt. Road Name:efFicif>A?n-Z '7li)Z.V
*,*NOTE**. This Authorization for WastewaterSystem Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pemtits. 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
1 7� yp IS VALIDFORA PERIOD OF FIVE YEARS
""$NVIRO HEALTH SPECIA 1 DATE ISSUED
y
t 1 ?J DAVIE COUNTY HEALTH DEPARTMENT
TMf'T{0 EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Per7nz 111 1
I e 4 u )
^Name: -1 'L ��'� - �+ �i Subdivision Name:
�.;
Directions toproperty:FI6'3Yfr'(4tl)'t , ` Section Lot: ��' � •
„�\5 IMPROVEMENT c
{L( F iEL t 6!9 e_eG: of o, PERMIT Tax Office PIN:#`:!�.-7 t5
!
ur-If f. d. " �+� l �Jb! (.� CK.CApd t1wcKS• Road Name: 0arlL f 4r' •^Zip: c'iL7$
**NOTE** This Improvement Permit DOES NOT authorize the construction orinstallation of a septic tank system or any wastewater system. Ail
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 I I of G.S. Chapter 130A, Wastewater Systems, Section :1900 Sewage Treatment and Disposal Systems)
i ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE .,
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
sxvlRoriMENra% HEALTH SPECIA�IS,T DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
n INSTALLING THE SYSTEM..
RESIDENTIAL SPECIFICATION: BUILDING TYPE • n *y_. # BEDROOMS _.�_ # BATHS 3 # OCCUPANTS -3 GARBAGE DISPOSAL:gse or No ..
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #SEATS _.INDUSTRIAL WASTE: Yes or No
LOT SIZE575%&C�7" PE WATER SUPPLY LL— DESIGN WASTEWATER FLOW (GPD) ")t.;(D NEW Srm 'REPAIR SITE
/l ,1 1
SYSTEM SPECIFICATIONS: TANK SIZE 12t) GAL. PUMP TANK\\ GAL. TRENCH WIDTH 3cm ROCK DEPTH 12 LINEAR FT. O
OTHER I D1_CxZ1�T/O,J �>G
REQUIRED SITE MODIFICATIONS/CONDITIONS: _ I !T ALk DA)
IMPROVEMENT PERMIT LAYOUT
k
A
L O
f 929tQ�-
**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
SYSTEM INSTALLED BY:{�'�'
"ItJ�t L"f�TC�
�Li cSTZn/` Lr�S�4lli
AUTH TION NO. - PERATION PERMIT B DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT SYSTEM DESCRIBED ABO 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. - -
DCHD 05,96 (Revised)'] -
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERIM fa
Davie County Health Department
Environmental Health Section U
P. O. Box 848 AM _ 8 19W
Mocksville, NC 27028
(704) 634-8760
ENVIRONMENT��yy is e�,ue� �
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES E COUPn
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billede_ i/�� �. ///YK—Tr..
w� Contact Person
Mailing Address %fi/ Q�LIP' r//:� ,1MJeat' R'el Home Phone "9 -03 / R
City/State/Zip /ybae lidy_ _ li e. Q 70 P Y Business Phone
2. Name on Permit/ATC if Different than Above 5 -AAA �
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
U'bishwasher
❑ Site Evaluation
❑ House l"Mobile Home
City/State/Zip
0' Improvement Permit & ATC I/ Both
❑ Business ❑ Industry ❑ Other
# People
# Bedrooms 3
#
Bathrooms
❑-Garbage Disposal
8'Washing Machine ❑ Basement/Plumbing
❑
Basement/No Plumbing
6. If Business/Other: Specify type
# Commodes # Showers # Urinals
# People
If Foodservice: # Seats Estimated Water Usage (gallons per day)
# Sinks
# Water Coolers
7. Type of water supply: ❑ County/City U-Vell 1 ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? B'�Yes ❑ No
If yes, what type?
A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 5.4 we S 1 WRITE DIRECTIONS (from
Mocksville) TO PROPERTY.,
Tax Office PIN: # 78�/' �' - 3�7v��3 ,
Property Address: Road Name fAY{'Yt- 2 1 ,
1 m e i
City/Zip MoekdIW,° N.e, aAP
;Alto
If in Subdivision provide information, as follows: 1 6A,1
Name:
1
Section: Lot #: %l
1
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 incuffed 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 J� c 1 Ls ee / 'lC Clrl�llllT/1 to conduct all testing procedures
as necessary'' to determine the site suitability.
DATE
Revised DCHD (06-96)
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• . DAVIE COUNTY HEALTH DEPARTMENT
Environmental' Health Section SECTION LOT A41
Soil/Site Evaluation
APPLICANT'S NAME QLb�rd
PROPOSED FACILITYY ` L
SUBDIVISION n�ttrt.,o 42/y"(,
DATE EVALUATED
PROPERTY SIZE�,`��v"�
ROAD NAME _5W4-_1aLQ t'✓J
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4 5" 6 7
Landscape position
L
Sloe %
HORIZON I DEPTH
— Z
Texture"group
C_
GG—
Consistence
S5 S
S
Structure
1t
Mineralogy
t r (
HORIZON H DEPTH
fZ-
Texture groupG
G
Consistence
Structure
Mineralogy
l:
t,
HORIZON III DEPTH
_ c F
Texture groupr
F
Consistence
S
Structure
1
Mineralogy
I•
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
5
LONG-TERM ACCEPTANCE RATE
e,11
SITE CLASSIFICATION: EVALUATION BY:C�
LONG-TERM ACCEPTANCE RATE: Q OTHER(S) PRESENT: C";, '1' LF ��
REMARKS: Rw C 4,4y . I i 6-vvp e J- cytr
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
oist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm , EFI - Extremely firm
Wet ' -
NS: Non sticky SS -Slightly sticky_ ._S -Sticky VS - VerySticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
tructure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineraloev
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)
LIAR - Long-term acceptance rate - gal/day/ft2
DCHD(01-90)
,�.
,. .. � �-x-01