369 Rabbit Farm Trail Lot 21'."�!{"uY�srh Y�+`rF ..z. •.�-i.a.��..x.rr.R.\,• '-;:1 _ter., ».,_ . �_; .�.. ... r_, _. ..; ,,::. ,. yr - .
-AU�tHORIZATION NO: DAVIE CDUNTY HEALTH DEPARTMENT ��
,Environmental Health Section PROPERTY INFORMATION
Permi[.:!e s c P.O. Box 848
Name:E�j Mocksville, NC 27028 Subdivision Name: %' I�%2
Phone # 336-751-8760
Directons to property: o—-,l��l Section: Lot: Z
, ') AUTHORIZATION FOR
*� } tj 1^J L"IjI j'"r WASTEWATER Tax Office PIN:# _i G%(�_
SYSTEM CONSTRUCTION (""
Z?cDfx-?r. -Tot\ILRoad Name: N,7A�rrA,
**NOTE**
This Authorization for Wastewater System Constriction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen -nits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Artic1 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t,:. i�L�,�1 IC) ?) 11 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON EIS T� EALTH SPECT ST DATE 1 SUE
It
169 0 DAVIE (BOUNTY HEALTH DEPARTMENT
'' "'✓ IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pelif r✓•
Name -.T,y ';i., Subdivision Name: r -y_ fir.
J
=Directions to property: 't'`l i '` ? 1t eL.-i. Section: Lot:
+ IMPROVEMENT
'd f i i t PERMIT Tax Office PIN:#"1`� -
t
Road Namel�'Phi vi\
**NOTE** This Improvement 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 Artic�e 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�,- }--- ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECI LIST, DATE ISSUED g INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE ILL). #BEDROOMS _ #BATHS_ #OCCUPANTS GARBAGE DISPOSAL es r No
COMMERCIAL SPECIIFICATION: FACILITY TYP,E.�, I # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE,I::W & ? TYPE WATER SUPPLY l DESIGN WASTEWATER FLOW (GPD) 3t� NEW SITE ✓ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE jj_J�D GAL. PUMP TANK GAL. TRENCH WIDTH 3& ROCK DEPTH iZ LINEAR FT. �
OTHER ` ( �! 151 ell�l/ 1! ,eJ :60)(
REQUIRED SITE MODIFICATIONS/CONDITIONS: rJ Q! L orJ c �1Tc�JP F (r1: i' Nat^ IQ 1,21-r
OPERATION PERMIT
w
2
SYSTEM INSTALLED BY:
n
o
t � ,
J t9)WLLl
1Z„ _ t
u'
AUTHORIZATION NO. 0q V OPERATION PERMIT BY: DATE: 00
tl
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY M DESCRIBED A OVE 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 051% (Revised)
APPUC4HON FOR SITE EVALUATION/IMPROVEMENT PERMIT &
Davie County Health Department
�^ Envinonmenta/Health Suction
P.O. Box 848/210 Hospital street OCT 1 419%
Mocksville, NC 27028
(336) 751-8760 ENVIRQNh1ENTAL HEALTH
***IIdPORTAN"** THIS APPLICATION CANNOT 8E PROCESSED UNLESS ALL THE REQUIRED
]INFORMATION IS PR(MDED. Refer to the INFORMATION BULLETIN for instructions.
1. !lame to be Billed M A -A. C EA—s W f1 Contact Person fUvA-,t L. yq_ ' e4,, t LQ
Mailing Address Soy S OC)LLL lD►4v \ S cx Berme Phone (4 34. - 7 12- -7
City/State/ZIP C %A m ov- S N(. 2.7 D 12 Business Phone 13 3 2.300
Z. flame on Permit/ATC if Different than Above
Mailing Address
3. Application For: 0 Site Evaluation
4. System to Service: [-House 0 Mobile Home
City/State/Zip
0 Improvement Permit/ATC Wlg; th
TF ?e4t, L.".1.
0 Business 0 Industry 0 other 46-'a
s. If Residence: # People . # Bedrooms 3 # Bathrooms 3
& Dishwasher eGeetbage Disposal N'NasbIng Machine O Basement/Plusbing 0 Basement/No Plumbing
6. if Business/Industry/other: specify type # People # Sinks
# Commodes # showers # Urinals
# Nater Coolers
IF FOODSERVICE: 11 Seats Estimated Water �Ussaage (gallons per day)
7. Typo of water supply: 11County/City "W 11 0 Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? D,'6s 0 No
U yes, what type. A D 0 CnIZ4-V w A'k
t "IMPORTANT " CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUES-TED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: !�s� �'� X SOS ���" gIROGTI (from Mocksville) to PROPERTY:
Coo a� 58?0� J51 Gq b4 X00 �
Tax Office PIN: # 9 000 , "�� � Cor:l.��TZ R�
Property Address: Road Name?ANAi r T&w-*74L4 1 CIO -10 IZrtg(3 tT aa2w,-rvt-v��
�OTi1
City/Zip �.Ju�"TL-1 (,_�. �PA6 GJ4�2w� . �j fl I�CC�I,uSC iLrA•��c�r
If In a Subdivision provide information, as follows: —TVU& Q, S -tr 4 flow -kohy& 4-a 2iSl k -4
Name: gg;-r A -A -RA -A- Loz- Z1 'p(,-, LqrTsi& o-,-- Rmw+ -M A�1 A
Section: Block: Lot: Z 1 Date Property Flagged: 1 Of t b 01 S
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)
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, andawand that I am reaponsiblefor 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 : ohm 14
to conduct all testing procedures as necessary to determine the site su'y a1 . 71 _„
DATE /D - /* - _l b SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Lvr zI
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION
Soil/Site Evaluation
APPLICANT'S NAME M*' U-CdTL�
PROPOSED FACILITY
SUBDIVISION "h/
Water Supply:
Evaluation By:
On -Site Well
/ Community
Auger Boring V11"
Pit
Z LOT ZI
DATE EVALUATED 1 (D) 1L
PROPERTY SIZE e�
ROAD NAMEI/'t
Public
Cut
FACTORS
12 3 4 5 6 7
Landscape position
/�
Slope%
j
HORIZON I DEPTH
p
TexturegroupCL
v
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
Consistence
<
Structure
fG
Mineralogy:
HORIZON III DEPTH
-
Texture group
Consistence
r
Structure
Mineralogy1:
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
p.
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
DCHD (O1-90)
Landscape Position
EVALUATION BY: A—rf153mkil
OTHER(S) PRESENT:
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
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 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
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