241 Dublin Road Lot 11AUTHORIZATION NO 0778 :. DAVIE COUNTY HEALTH DEPARTMENT Via.
r R G a u I I�Environmental Health Section PROPERTY INFORMATION
Pernutte¢ s /,% P.O. Boz 848:
Mocksville; NC 27028 Subdivision Name: Ant
Phone #. 704-634-8760 r
Directions to property: — - Section: Lot:'
.� AUTHORIZATION FOR �,
1• WASTEWATER Tax Office PIN:#5 ( /' +�
��r111 SYSTEM CONSTRUCTION " !
Road Name: &rbl, r>..p ��a 60
**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 applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 1304, Wastewater Systems, Section'.1900 Sewage Treatment and Disposal Systems)
j ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS
'ENVIRONMENTAL JiEAL4111 SPECIALIST:. _DATEISSUED. _ . .... ...
Ai DAME COUNTY HEAURDEPARTMENT
'F\ G j3 (,(j ROVEMENT AND OPERATION PERMITS PROPERTY INFORM TIO
A N-
Pb'rnu
-Subdivision Name:
Diiectionsto propert Section: Lot:
IMPRONthlENT
PEI?
ruff
t
Tax Office PIN:#Vff - . r d -3�0:5
Road Name: Ip
"NOTE**This Improvement Permit DOES NOT authorizeffie 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 1:
constructirnarmstauation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.& Chapter 130A, Wastewat6r Systems, Section. 1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE.
/f I
PLANS OR THEINTENDED USE CHANGE. YOUR WASTEWATER -
ENVIRONMENT AT HEAIhHSPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TE LS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE H #BEDROOMS-�' #BATHS :2- # OCCUP ANTS
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 srrE--Z�REPAIR SITE
SYSTEM SPECIFICATIONS: TANK sizE,2,MkGAL. PumF TANK —GAL. TRENCH WIDTH ROCK DEPTH 1.2". LINEAR FT. :f,9 6
OTHER
REQUIRED SrIEMODIFICATIONS/CONDMONS:
I
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:39- 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
DCHD 05/96 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT
Davie County Health Department
r - 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. // �j
1. Name to be Billed T) b4 ev K QA 'E� tea 2 Contact Person l4 � � be✓l I� o C P✓
Mailing Address �5-2 LLS' U °S I I war ISR'Home Phone C79 FS - 7? 33?
City/State/Zip A Ay f H W 0 C- M- 0. 2-7 bb Cn Business Phone C'Z 9&:- 8 3�
2. Name on Permit/ATC if Different than Above C
Mailing Address Ll)'q /-4 'e City/State/Zip t5 t9-64 -2
3. Application F Evaluation M improvement Permit & ATC [ ] Both
4. System to Serve: [vfticuse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms # Bathrooms_ [1 j Hishwasher [ ] Garbage Disposal
L,J,Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers' # Urinals # Water Coolers
If Foodservice: # 4eats 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 [ ] No
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A3MVFOF THE PROPERTY MUST BE
SUBMITTED WITH T�iI,S APPLICATION.
Property Dimensions: �e5 U jC a b b )( /6-0 X o2 bb 1 WRITE DHtECTIONS (from Tr
TO PROPERTY:
Tax Office PIN: *-5193— - ` - 3S7
Property Address: Road Name U b j W QJ
City/Zip A c�J Va nl 0 P Al 0 376 b
If in Subdivision provide information, as#ollows:
si
Name: _{ J 1 ✓1 N r 0 Clam' C✓ 25
Section: r Lot#: 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 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 FF t-1 A &A -W,1 ✓ A - to c9pduct all tes 'ng prr`occeedures as necessary to determine the site suitability.
DATE LF ` SIGNATURE
Revised DCRD (06-96)
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN: jt
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation /� J
NAME CC/v t�G(II�C r-s�/ DATE EVALUATED
ADDRESS �� �Y1�l%-�OCk /7 �� PROPERTY SIZE /J
PROPOSED FACIILTY 9912 �� LOCATION OF SITE L'/ e
Water Supply:
'Evaluation By:
On -Site Well
AugerBoring -
_ Community
- Pit Ll_�
Public
Cut
Slope Z
HORIZON I DEPTH
FACTORS
1 2 3 1 4
Landscape position
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTHg..r
1/O
Texture groupG
Consistence
r i
Structure
i e
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 t(
SITE CLASSIFICATION: ! J
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
-EVALUATED BY: '4r l
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 FP -Flood plain H -Heed slope
Texture
5 -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-Ve-y 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
3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralorry
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/fta