484-492 Hobson Drive Lot 31B, Section AI �Xo
AUTup>al,'.'TION NO: 1522 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's ' P.O. Box 848
Name: Mocksville, NC 27028 Subdivision Name:
f �—^ Phone # 336-751-8760
Directions to property: ��' _ i S�! r'r Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#d
Road Name: d /✓—ozip:
**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 I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
:NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
= 1522
22 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name:'"� t� - ✓' � � Subdivision Name: D /
Directions to property:' /� is -p' { j ' Section: Lot.
IMPROVEMENT
PERMIT Tax Office PIN:�I�
Road Name:
**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 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
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS_ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE'" TYPE WATER SUPPLY �(l DESIGN WASTEWATER FLOW (GPD) � NEW SITE � REPAIR SITE
SYSTEM SPECIFICATIONS: TANKSIZEZOAO GAL. PUMP TANK GAL. TRENCH WIDTH 3 / ROCK DEPTH 'LINEAR FT. W
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT.
"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 (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
.7p .
ST
� F .
AUTHORIZATION NO. 1 SZ"L OPERATION PERMIT BY: DATE: 4 1_
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBE BOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 05/96 (Revised)
i APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A I
R9 a l'r
ADavie County Health Department � v
Environmenta/Heaith Section c1�O
P.O. Box 848/210 Hospital Street AL 2 0 im
Mocksville, NC 27028
(336) 751-8760 __ __...._.._....�..�,.
***Il►PORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL � REQUIRE
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed L,,a /I/, L--` ' s
Mailing Address /' ' D j6U/r
City/State/ZIP eOOJeein a e-
2. Name on Permit/ATC if Different than Above
Mailing Address
Contact Person
Home Phone -- C 2s // "dry b 4,
Business Phone
City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC I?/Both
4. system to service: ❑ House Ii Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People 3 # Bedrooms _3
❑ Dishwasher ❑ Garbage Disposal W/W.hing Machine ❑ Basement/Plumbing
6. If Business/Industry/Other: Specify type # People _
# Commodes
# Showers
# Urinals
# Bathrooms _
❑ Basement/No Plumbing
# Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: WI-6ounty/City ❑ Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
o
I***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN AIUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: d( h(JLQCC�/ -
Tax Office PIN: # -!5-7 J3- 3�T�/ •y�aS TE DIRECTIONS (from Mocksville) to PROPERTY:
Property Address: Road Name /10A5v"' i
nA Boa
City/Zip -[7-0;6 " c'
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot: 3/ A3
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 4jounq HeqJ1th Departnlent
to enter upon above described property located in Davie County and owned by Y►• XPi �17Y1�ch
to conduct all testing procedures as necessary to determine the site suitability.
DATE 2a Aq SIGNATURE (, /� aAA�-
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
A c,�
-Appliesttion No.
Invoice No. l�
Revised DCHD (07/98)
21
23
25
27
29
30
IN
5745-526 oL I
5745-59--0-545
45
mall
5745-56-0566
5745-55-0487
5745-56-1306
5745-55-1225
31
5745-56-1147 v
5745-56-1057 \
5745-55-1997
5745-55-2807 ,
5745-55-2728
'36 x)
U 5745-55-5 5-2663
tel. ,fid
(10.05A)
5745-55-3145
INDEXED ON 5745.15
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME .•/�i%� DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION l� p ROAD NAME
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure $'
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
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
DCHD (01-90)
Landscape Position
EVALUATION BY: Al
T=
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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DAVIE COUNTY HEALTH DEPARYMEPIT
SEPTIC TANK PERI=iIT
No. of Bedrooms Date L__ i/ — &'
This permit is granted to ?S � g , T, for the installation
of a Septic Tank at the residence of Address
`�
Building Contractor C Address /7/ /., A(
Septic Tank Specifications: Length Width Depth Capacity Gai;
Manufacturer's Name Address
No.
of lines Width
in. Total length
ft. No. of Sq.Ft.,+
Type
of filter material
Total tons
used
Minimum Requirements:
House Trailer
Two -Bedroom House
Three -Bedroom House
Tank Capacity
_ --- 800
M
M
Square Ft. of Line
100
600
M
No one shall install a septic tank in Davie County without a permit from the
Health Officer or his agent.
Date of final approval Signed: / 9-
Sanitarian
I hereby certify that the above septic tank has been installed according to
specifications.
Signed f�
Septic Tank Contractor
Note: Make sketch of disposal system on back of sheet and mail to the Health
Center in 1Iocksvil1e.