356-370 Swicegood Street Lots 5A & 5B***NOTICE*** 7111S PERMIT ISSUBJECT TOREVOCATION rySITE
,-'
PLANS ORTHE INTENDED USE C�G&YOLJR WASTEWATER
ENVIR ALHEAL IST D -
SYSTEM CONTRACTOR MUST SEE TILS PERMIT BEFORE;��:,,
' A AIMS V,
"','INSTALLING THE SYSTEM � ;
RESIDENTIAL SPECIFICATIOR'BUILDING TYPE #BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes onvg---.'
COMMERCIAL SPECIFIcknom.. oAdiyibTy TYPE #'PEOPLE PEoPLE/sHiFr i SEATS INDUSTRIAL WASTE or No
F S
LOT SIZE"
0 TYPE WATER SUPPLYC&2�d; DESIGN WASTEWATER FLOW (GPD) STfE
REPAIR SITE
••,•y.�.. ..o.untn. mrimso a All;
Davie County Health Department �PJ
Envlronmentalflealth.4er 0,7 '
P.O. Box 848/210 Hospital street
Nockaville, HC 27028
(336)751-8760
+++IIWORTANT►++ THIS APPLICATION CANNOT SS PgpC SgED DNLESS ALL TH
INFORMATION IS PROVIDED. Refer to the INVOrMATION BULLETIN ctionsQtlIBED
£or iaE AEREQUIRED.
1. name to be Billed
nailing address
city/state/LIP
2. Name on pewit/ASC :,f Different than Above
Nailing Address
3. APplioation For: U Site Evaluation
6. system to service: ❑ House L��'Rob-ile Home
S. If Residence: # People I
D Dishwasher 0 Garbage Disposal
contact person
Nome Phone
Business
City/stats/zip !rA, -
❑ Improvement Permit/ATC th
❑ Business ❑ Industry ❑ Other
# Bedrooms - _q_ # Bathrooms
D Hashing Machine
6- If Business/Industry/other: specify type
/ Commodes f showers
IF FOODSERVICE: # Seats
7. 2"s of water supply:
0 Basement/Plumbing
# People
# urinals
0 Basement/No Plumbing
# sinks
# Nater Coolers
Estimated Water usage (gallons per day)
Wcounty/City
Wdell
s. Do you anticipate additions or expansions of the facility this system is intended to serve?
H yes, what type?
U Community
0 Yes ❑ No
***IMP0RTANT*+* CLIENTS AftrST COAfPLET ETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN dIUSTBESUBMITTED by the client with THIS APPLICATinn:
Property Dimensions: /—G • /3�T j /� WRITE DIRECTIONS (from Moccbville) to PROPERTY:
Tax Office PIN: N ! �J —'i' �q �/ T (Q��i)Qf O I S 7066� O O I S
Property Address: Road Name a' t S f- 7 Ze F *0c
.J�t/1 L B 4V
City/zip e¢ y,) LO C
If in a Subdivision provide information, as follows.
Name: _ D -m l l ;A v---
Section:
"Section: Block: Lot: gg
Date Property flaed:
This is 10 certify that the Information provided is correct to the best of my knowledge. I understand that any permil(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, atm, understand that I am r 70DA/e for 011 charges Incurredfrom
this aPPUcadom 1, hereby, give consent to the Authorized Representative of the Davjq County Health Deparlmen
to enter upon above described property located in Davie County and owned by _ /'j p 4 py — f �, ii
to conduct all testing procedure ns necessary to dNermiNe the site wits li rn)gef
DATE 9 ,r� SIGNATURE � Ign
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (lncluddfll of the
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/98)
Existing and proposed
Account Na
Invoice No. __ �9
DAVIE COUNTY HEALTH DEPARTMENT
FACTORS
1
2 3 4 5 !6 _ 7
Landscape position
Slope %
-20
HORIZON I DEPTH
0-10
Texture group(�
G`
Consistence
Structure
Mineralogy
HORIZON H DEPTH
40- q0.
-
Texture group
G
Consistence
17 $17-
S7
Structure
1
)L
Mineralogy/
HORIZON III DEPTH
- Lf
Texture groupk
5
Consistence
r 5
Structure .
5C13 Ic
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
b , -
SITE CLASSIFICATION: 2 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: J 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 - 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
MOW
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 -tern acceptance rate - gal/day/ft2
ncan(0)-90)
iiia
MEMO
NONE
■■E■■
■■■E■
■■EEE
■E■■M
IORi ATION NO .1 8 5 2 DAVIE,CpUNTY HEALTH DEPARTMENT
"< { nvtronmental Health Section PROPERTY INFORMATION
i� .. - P O BOX 848 .1.
**NOTE**,This Authorization for Wa:
to issuance of any -.Building
Office-whenapplying for.B
an cmmnliance'with ATtIP1P'I Cnf G 4�:1
?111 ra391 :.Mocksville; NC,27028 Subdivision Name
***NOTICE*** TRIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
VALID FOR A PERIOD OF FIVE YEARS
E TH PE IST',.' DAT ISS ED "'
,IR NM NT t:HEAL
r ' 3 *'E*NOTICE***THIS PERMIT IS SUBJEUT TO REVUCA 11UN RN -WI -E!
CI SPI ANS OR THE INTENDED USE CHANGE YOUR WASTEWATER
tr i r Z
�ENVBiO AL HEALT 'sPE IdLIST DA ISS D SYSTEM CONTRACTOR MUST SEE TILS PERMIT BEFORE"
:. ALLING THE SYSTEM
_: BUILDING TYPE
RESIDENTIAL SPECIFICATION
#BEDROOMS ,►-� #BATHS' N OCCUPANTS
GARBAGE DISPOSAL: Yes
COMMERCIAL SPECIFICATION: PACILITY TYPE
#PEOPLE '. #PEOPLFISHTFC_.,#SEATS :.
INDUSTRIAUWASTE Yes or No
Z OF
WASTEWATER FLOW NEW SITE
r REPAIR SLfE '
LOT SIZE TYPE WATER SUPPLY
SYSTEM SPECIFICATIONS:JANK SIZE IL�XZGAL
DESIGN (GPD) ,
PUMPTANKGAti' I�� EPTH f2 LINEAR FT. `'
"" .TRENCH WDTH ROCK D
- OTHER I'I�S-r2lgit
Lr oa
'
STA:-�- : �OOe. .,.•U�E.,".
�l2jR . '
REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 !J
/iN _�1' "CaK
IMPROVEMENT PERMIT LAYOUT.,
71
`
µ
r
I
c
,J
O
r
Davie County Health Depatfinent _
Environmen[a/Hea/th5L*cd+on
P.O. Boz 848/210 Hospital Street
Moakaville, HC 27028 NOV 2 5 17011
(336)751-8760
ENVIRONMENTAL
:**L*ZW0Jt7A1ff*** THIS APPLICATION CANNOT IM PROCESSED MUMSS ALL TBE REQtlIRED
INFORl41TION IS PROVIDED. Refer to the INPOR4fATION BDLLETIN for instructions.
1. Nam to he Billed
Nailing address
City/state/LIP
a. Name on Peau/Are if Different than
Nailing address
3. Application For: ❑ Site Evaluati
on
t. system to service: 119 House 12obile Hose
a. If Residence: i People
n Dishwasher ❑ Garbage Disposal
i rnezContact Person
Name Phone
MON- Business Phone
rzwmnyc
City/state/sip -- f�yyI
❑ Improvement Permit/ATC th
❑ Business ❑ Industry ❑ other
i Bedrooms —?
D Washing machine
6. If Business/Industry/other: specify type
6 Cemmedes / Showers
O Basement/Plumbing
/ Bathrooms �Z_
H Basement/No Plumbing
# people / Sinks
i Urinals 0 Water Coolers
IF FOODSERVICE I Seats Estimated Nater Usage
` (gallons per day)
7. Type of water supply: SSS ounty/City well
❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve! ❑ Yes ❑ No
H yes, what type!
***IMPORTANT"** CLIENTS AfUSrCVAfpZ7ETETHE REQU/REDPROPERTYINFORMATIONREQIJESfED
BELOW. Elther ■ PLAT or SITE PLAN AIUStBESUBMITTED by the client with THIS APPLIVATinm
Property Dimensions: ,Ax L • -6
Tax Office PIN: N
Property Address:
WRITE DIRECTIONS (from Mocluville) to PROPERTY:
Road Name
City/Zip eQ 7n L7 ('�
If in a Subdivision provide information, as follows: 9A,/(//
Name: 4
L-
2
i
,
I o r—
Section: Block: toot: "D
Date Property Flagged: /% ;Z 17 �jo.
This is to cerlify 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 falsilled or changed. I, also, anAnwaad that I on rrsronA&Iefor all charges iacsmed front
this affUcadon. 1, hereby, give consent to the Authorized Representative of the D&VIP County Health Departmen
to enter upon above described property located in Davie County and owned by _ 104 2r — J r — ju t��,pcl S
to conduct all testing procedures as necessary to determine the site Gita II .
DATE —2 SIGNATURE7)
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN Oncluddfdl of the Tollo/og: Existing and proposed
Property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (o7/98)
Account No.
I�
Invoice No. 9
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOTSS
Soil/Site Evaluation
APPLICANT'SNAME r' t�L✓1^�
PROPOSED FACILITY
SUBDIVISION
DATEEVALUATED' �ZIl�tb�
PROPERTY SIZE • 3 7G A -e -
ROAD NAME1G3(>oop 5�
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring
Pit `
', - Cut
HORIZON I DEPTH.
p '.
' FACTORS''
1
2 3 4 .. +5 6 7.
Landscape position -
L
!,
Sloe %,
(o
HORIZON I DEPTH.
p '.
Texture groupG�
Gc
Consistence :
/-5
Structure .
I, ---
LMineralo
Mineralogy
f; I
i
HORIZON
II DEPTH .
-10
Texturegroup
G 1
11
Consistence
F;
S
Structure
S 7L
Mineralogy
HORIZON III DEPTH
-
O -
Texture groupC
G+
Consistence
$
Structure
k
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: - EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: b T 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 slopeT - 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
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)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD(01.90)
■oo■
iii■
e
a