515 Rabbit Farm Trail Lot 14�� .. iG d.•3 y y x . f. '"' Y`a;�,.i !y"' Pi- y avaz. +. .r :Y .ra 'i Y'lT�-•:?�4'f y,,,.4a. a.e' :. e { . , • . -- r -.. y _- _ y ;.e. r..�_ Fq , '.
r " i C!7/S � Tjj� . fa,y'Y4'„�3 . s `irar e' eydti y • e y -.:,1I- .y.., 4�•,pY 7: 'J
AUTHORIZATION NO: _ : / !,%� DAVIE COUNTft;ALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Perrrii[tee'ti ` - } P.O. Bob $48
Name:~ �Mocksville, NC 27028 Subdivision Name:'
IC) Phone # i.
Directions to property: �`�i4r r-+�'`.336-7.51-8760.Section:. ` Lot:
{ [p�''�, AUTHORIZATION FOR
.'L t�� 4: Ari` (� WASTEWATER. 1C _'`�C� `)c)
�,_ , �� i� � t�--.-. Tax Office PIN:# � �- _ -
SYSTEM CONSTRUCTION
~ 1 U r� X1 —I' Ufa �-
�i.n5 Road Name! AA Ill �y`�A:�
**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 fuilding Permits.
(In compliance wi icle I 1 of Gr. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FORA PERIOD OF FIVE YEARS.
ENVIROKN! AL,HEALTH SPECIA ST ) DAT ISSU Q
.. . _ ..t W i+, ,� f•'.1 �. t ...4. I" '.y,,- t til.. - ..
;� - •_ DAVIE COUN HEALTH DEPARTMENT+
1 ^� IMPROVEMENT ANP OPERATION PERMITS PROPERTY INFORMATION
Pe`rnMie�'�.! y 1
Subdivision Name. .. ;
Dtrectionslo-property: ; r Section: Z Lot:
IMPROVEMENT
PERMIT. Tax Office PIN:#�° �. <
L Road Name!--4,.�t";`11 F .ip:
**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 Article 11 of Grp. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
�. r2 ,, ,,: � _ _, , -j � PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
_ENVIRONMENTAL HEALTH SPECIALIST DATIjISSUEb SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE C.# BEDROOMS _.� # BATHS Z_ # OCCUPANTS ° GARBAGE DISPOS es br No
COMMERCIAL SPECIFICAATTIION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT
�,# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE /�~� YPE WATER SUPPLY�L DESIGN WASTEWATER FLOW (GPD} -ta(t "' NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZJDD GAL. PUMP TAN^K- GAL. TRENCH WIDTH.�(a ROCK DEPTH !� LINEAR FT.--"'�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: r�SJ QLL UrJ C:i>� f(� t N� 4-x -1" 60 F es- 1,)!t
IMPROVEMENT PERMIT LAYOUT InPPROVED 'ETrFLU34T FILTER*
aefiiE�-
5,J
'rt
a5 w
A CFRr::��. `c- o'
611 BELOW FINISHED GRADE*
"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)g341106W. X
(336)751-8760
OPERATION PERMIT
AUTHORIZATION NO. 1s1- N OPERATION
SYSTEM INSTALLED BY: _
at
PE IT BY:
"THE ISSUANCE OF THIS OPERATION PERMIT SHAL INDICATE THAT THE STEM DES
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1 00 "SEWAGE TRE ENT AND DlI
GUARANTEE THAT THE SYSTEM WILL FUNCTIONS XSFACTOR OR ANX jyiVE
DCHD 05/96 (Revised),IU' S
?kAf
am
Sr
ED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
�L SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
OF TIME.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 848 1 ' '
Mocksvillo, NC 27028
(336)751-8760 hl';�71lhc�,IH
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE NI iE CilU.1Tp
—�-
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Nattte to be Bitted /fie G 1 Contact Person Lt 4"
Mailing Address Q 2 Lj IJ �nok-t oro e\ee- Ccv�-3 Home Phone , :3 b " %�( �i-d O 2 %
City/State/"Lip wiAis��n-Sclp-lu. N C.- 2--7/0 Business Phone 33 b - �`� - S-1 �)7
2. Name on Permit/ATC if Different than Above Same
Mailing Address City/State/Zip
3. Application 1~ot: 21, Site Evaluation improvement Permit & ATC •E�oth
4. Syste n to Serve: ;k house 0 Mobile biome O Business O Tndustry a Other —_
5. If Residence: # People 4— # Bedrooms 3 # Bathrooms _2//Z
�R_ Dishwasher '.9 -Garbage Disposal 0`. Washing Machine O Basement/Plumbing U Basement/No Plutnbing
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: O County/City W- Well 0 Community
8 Do you anticipate additions or expansions of the facility this system is intended to serve? Cl Yes %I No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***A P4AW THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 30 o )C i o tl a k 3o 0 K L 1 3 Z IRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Tax Office PIN: 0
ni C�,s� 6 or o
Property Address: Road Name �-o�' �4 Kc����' Farb. Tf c.1 1
Le-fA
City/;Lip 2702(o 1
I c�1 I
YJ�7' or'w. rel
If in Subdivision provide information, as follows:
i
Name. -
Section; Lot #: 14
f
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. 31so. understand that I am responsible for all charges incurred from this application. 1, 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 fl ri •._ eoT to conduct all testing procedures
m, necessary to determine the site suitability.
DATE _��� . LLSIGNATURE �-
Revised DCHD (W-96)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME N C'
PROPOSED FACILITY 71 14n, rX
SUBDIVISION 1
Water Supply:
Evaluation By:
On -Site Well
Auger
SECTIONy LOT2
DATE EVALUATED 15
419,
PROPERTY SIZE �- 4C1��ppn�9
ROAD NAME ' 'O) c—w,,,,.- c -t-" (✓
Community Public
Pit Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
Sloe %
a
HORIZON I DEPTH
o -
0-i
Texture groupL
v
Consistence
t
51j
Structure
Mineralogy
l,'
HORIZON II DEPTH
. I
Texture group
Consistence
r S
Structure
-SG3tL
k
It
Mineralogy
C
t*' 1
HORIZON III DEPTH
-3�0
Texture group
Consistence
S
Structure
Se -
L
Mineralogy
1<
i
HORIZON IV DEPTH
Texture group
Consistence
Structure
G
Mineralogy)
�
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
5
LONG-TERM ACCEPTANCE RATE
cTTVrT AeeTMrATTnw,
RVAT.TTATTnNRY•
LONG-TERM ACCEPTANCE RATE: C)' q
REMARKS:
LEGEND
DCHD (01-90)
Landscape Position
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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