241 Sheffield Farms Trail Lot 2***NOTICE?**THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A'PERIOD OF FIVE YEARS.
"ENVIRONMENTAL HEALTH SPECIALIST. DATE ISSUED
p 6A DAVIE COUNTY HEALTH -DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Names el,r�J_//. k Subdivision Name : �✓ i'f
Duechonsfopro peRy f� %i 1 r% Section: Lof.'
IMPROVEMENT '
PERMIT Tax Office PIN:# i' P .�%r
—�
Road Name:..�fY
**NOTE** This Improvement Permit DOES NOT auth6hie 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
constiu6tiontins0ittion of a system or the issuance of a building permit:
"'with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section. Sewage Treatment and Disposal Systems
(Ili coinphailce ) . '
.... ***NOTICE*** THIS PERMIT IS SUBJECT -70 REVOCATION IF SITE -
PLANS OR THE INTENDED USE CHANGE. YOUR �WASTEWATER-
ENVIRONMENTAL T SYSTEM CONTRACTOR MUST SEE.THIS PERMIT BEFORE .
HEALTH SPECIALIST DATE ISSUED - .-+
. ,. �:INSTALLING THE SYSTEM.
::'-
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS ,_.�_ # OCCUPANTS GARBAGE DISPOSAL Yes or No
COMMERCIAL SPECIFICATION: FACILITY.TYPE„ # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOTS TYPEWATERSUPPLY: DESIGN WASTEWATER FLOW (GPD) NEW SITEt
SYSTEM SPECIFICATIONS:. TANK SIZEA400 GAL., PUMP TANK GAL.- TRENCH WIDTH ��ROCK � REPAIR SITE
'
. DEPTH L"��'I.INEAR FT. ,r4J di
OTHER ,
REQUIRED SITE MODIFICATIONS/CONDMONS:
**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 904i6Mj89RBt
(336)751-8760
DCHD 05/96 (Revised) :.
`;;�ti
FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848 NEW PHONE NUMBER:
MocksviRe, NC 27028 EFFECTIVE MARCH 22, 1998
,(-704) 634,8769 _> 336 751-8760
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed i i \ raA Q UJ 0
Mailing Address ,o((l (l� i �� O W Q !e.e'ete_. L h
City/StateMZ� /q t_' ai O A Y
2. Name on Permit/ATC if Different than Above
Contact Person s A-YY%9—
Home Phone
Business Phone
Mailing Address City/StateiMp --
3.
-3. Application For. [ S,ite Evalu n [y7mprovement Permit & ATC VBoth
4. System to Serve: }+]`House Mobile Home (] Business [ ] Industry [ ] Other
5. If Rest nce: # People3_ # Bedrooms _ # Bathrooms—a—[ ishwasher [ ] Garbage Disposal
If
Machine [) Basement/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 [41 ell [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ ]'No
If yes, what type?
,a c.
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: **+ IMPORTANT ***�• OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: s' A: WRITE DIRECTIONS (from Mocksvllle) TO PROPERTY:
Tax Office PIN: # 8i 1� r.0D'
Property Address: Road Dame S'r�W`i vta� Rte' @,a
Clty%Llp lYlacKSo:II,( 22028'A •Q,L--tt�--rt,J
If in Subdivision provide information, as follows: e-%k—
Name:i%sQ
Section? Lot#: a OAr£�T.OP61P?y 1%AGGED% ?v CiY'�
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 to conduct all testing pros.
S
DATEZ -,. SIGNATURE a.; -R Q
Revised DCHD (06.96)
THIS AREA MAY $E USED FOR bRAWING YOUR SIZE PLAN:
as necessary to determine the site suitability.
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411
DAVIE COUNTY HEALT
DEPARTMENT
Environmental He It
h Section SECTION_/—LOT
Soil/Site Evalu
tion
APPLICANT'S NAME ///A�/
DATE EVALUATED
PROPOSED FACIISTY
PROPERTY SIZE O%1
SUBDIVISION
ROAD NAME
Water Supply:, On -Site Well ✓/ -' '` Community
I Public
Evaluation By: Auger Boring ✓ Pit
Cut
FACTORS 1 2 3
4L 5' 6 .. 7 -
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure .
Mineralogy
HORIZON H DEPTH /e r
Texture group Ci
Consistence i
Structure 9L b
Mineralogyi
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON W DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLTTE
CLASSIFICATION J.
LONG-TERM ACCEPTANCE RATE
SITE CLASS IFICATION
EVA LUATION BY:
LONG-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 7 Flood plain H - Head slope
Texture
I
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
gist I
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
Sapiolite - 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
3CHD(01-90)
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