371 Hobson Drive Lot 9�AUTHOF.IZATION NO: "0 8 8 2 DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section PROPERTY INFORMATION
Permitte ' � Q P.O. Box 848j5. �" ( r i:•s�a
Name:Mocksville, NC 27028Subdivision Name*
r
Directions to propertyPhone #: 704-634-8760`. -5ti_ L� Section: Lot:
C.� AUTHORIZATION FOR r _
WASTEWATER. Tax Office PIN:#J�5 - 5
SYSTEM CONSTRUCTION
Road Name: )Alf-�..Zip:
910
**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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
._,., DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INkORMATION
Permitteg;
Name: = Subdivision Name. g>
Directions to property: (d� -'� t'� Section: Lot:
r IMPROVEMENT
PERMIT Tax Office PIN:#. ` " `• ry _ '� 4 �'R ,
Road Name
�: �') \i r' 6n rt rah
yk Zip:
**NOTE** This Improvement Permit DOES NOT authorize the constriction or installation of a septic tank system or ��/ny wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Ddpartment 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 TILS PERMIT BEFORE
INSTALLING THE SYSTEM.
f
RESIDENTIAL SPECIFICATION: BUILDING TYPE ,,44 BEDROOMS 5 # BATHS S)— # OCCUPANTS GARBAGE DISPOSAL: Yes 1 r
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS /INDUSTRIAL WASTE: Yes or No
LOT SIZE Q�t ��p��V
TYPE WATER SUPPLY ��. DESIGN WASTEWATER FLOW (GPD) ..J � NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 1 Q22_GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH) LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
y:
r�
i
o
"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) 634-8760.
OPERATION PERMIT + _
3 SYVMINSTLED INS � p �
t ep
r
AUTHORIZATION NO. OPERATION PERMIT BY: ��'�/ / DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 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)
r • APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
- Davie County Health Department j`\
Environmental Health Section
P.O. Box 848
` . Mocksville, NC 27028�+��{ 91997 �?
(704) 634-8760
i
**IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED L�*
THE REQUIRED INFORMATION IS PROVIDED.
1
l.. Name to be Billed t / R/I Contact Person
Mailing Address car,Home Phone_ 2?1/-2 gfo S
City/State/Zip KUye- Business Phone
a:
2 Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip _
3..Applicaticn For: [ ] Site Evaluation [ ] Improvement Permit &,ATC ' [ ] Both
1 4 System to Serve: [ ] House [rJ Mobile Home [ 1 Business [ ] Industry [ ] Other
5. If Resider ce: #People _ #Bedrooms _ #Bathrooms __ [ ] Dishwasher [ ] Garbage Pisposal
[ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Busine: s/Other: Specify type # People #Sinks #Commodes
# Showers # Urinals # Water Coolers
? If Foodservice: # Seats Estimat71m,ell
ter Usage (gallons per day)
i 7. Type of water supply: [ ]County/City [ ] Community
+,
8: Do you anticipate additions or expansions of the facility this system is intended to serve? ( ] Yes [ ] No
If ves. what tvne?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A,OF THE PROPERTY MUST 13E
SUBMITTED WITH APPLICATION.
Property Dimensions: Z-1).i� 2 6r I WRITE DIRECTIONS (from�Iocksville) TO PROPERTY:
f Tax Office PIN: # 17YS- - _ -?6so ; Eel %O (A e4 /' rdl 436
Property Address: Road Name /�a�d &�l�l ��. �f o%r;�6f� %��_�_o �lCt
City/Zip A4c,- Sy VZ
If in Subdivision provide information, as follows: - _-
i Name:. �V i Aa i
Section: _ Lot #:�3,,!Y, 7,i
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,,,
i
changed. I,_ a.so, 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 to conduct all testi proceds as necessary to determine the site suitability.
DATE '� --Qf 2Z SIGNATURE
Revised DCHD (06-96)
THIS AREA MAY $E USED FOR DRAWING YOUR SITE PLAN:
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Seat this u day Of \
• - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME `-�'�•\\ S -
PROPOSED FACILITY
SUBDIVISION
Water Supply: On -Site Well " Community
Evaluation By:e_�\__'; Auger Boring Pit
SECTION LOT
DATE EVALUATED 9-1
1DPnPF11?TV Q17P Io , a&D'
ROAD NAME
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
_ o
O
HORIZON I DEPTH
L 0
°
Texture groupC_
L
Consistence
F�
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
SS
S
RESTRICTIVE HORIZON
—
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
1A–1
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: 34
REMARKS:
DCHD (01-90)
LEGEND
Landscape Position
OTHER(S) PRESENT: 1
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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