465 Hobson Drive Lot 20AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT
.;'
1363 Environmental Health Section PROPERTY INFORMATION
Permtttee's ., , #!_ P.O. Box 848
-Name: �w `x. � w� 'I' Mocksyille, NC 27028 Subdivision Name:-
1 Phone #: 704-634-8760
Directions to property: Section: Lot: e.19-4
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#•/`::
Road Name: ip: At le i ly
**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
f IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
+� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS
PMittel
Directions to property:
PROPERTY INFORMATION
Subdivision Name: <a,*�'�','� Rep
Section: Lot:''
IMPROVEMENT r.:
PERMIT Tax Office PIN:# •�' - -
Road Name Zip: e"
**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 T_ # BATHS _ 9 # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE D(i JG U TYPE WATER SUPPLY K10 DESIGN WASTEWATER FLOW (GPD) NEW SITE—tZ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE k'4 GAL. PUMP TANK GAL. TRENCH WIDTH -��' ROCK DEPTH J� LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
4
1
**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
SYSTEM INSTALLED BY:
S �
S
MNbT�
. 4NkL � G�
\ Sl7ti
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)
1
er APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC "
Davie County Health Department
cA
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(70��
(336)751-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
�+ ALL THE REQUIRED INFORMATION IS PROVIDED.
Name to be Billed (�!' .S; Sar.- in +� Contact Person
Mailing Address //4 ,S�oi7 �l . Home Phone
City/State/Zip age es- I& Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
❑ Dishwasher
❑ Site Evaluation
❑ House Mobile Home
# People N
City/State/Zip
❑ Improvement Permit & ATC
❑ Business ❑ Industry
# Bedrooms ,.2o r .3
Both
❑ Other
# Bathrooms _=
❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type
# Commodes
If Foodservice:
7. 'Type of water supply:
# Showers
# Seats ��
® County/City
# Urinals
# People # Sinks
# Water Coolers
Estimated Water Usage (gallons per day)
❑ Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes ❑ No
ZL IHEK A MAI UK NITS PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PI+X'HE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: / 1 WRITE DIRECTIONS (from
r
Tax Office PIN: # ' - �^ 1 Mocksville) TO PROPERTY -
1'61 - � A� 1
'61 f
Property Address: Road Name ' 2t 1
1 /i4 On o CY
City/Zip Ac 'S✓ile 220,22
1 An 6.411 d�
If in Subdivision provide information, as follows:IQ 1
4 Name: C e 1
1
Lot #•
Section 1
it
� 1
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 Representativeofthe Davie County Health Department to enter upon above described property located in Davie County
and owned byj%lL� �`%�`'� to conduct all testing procedures
as necessary to determine the site suitability.
DATE " 02 " GI SIGNATURE
Revised DCHD (06-96)
YOU MA1J. USE THE $ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN.
0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME , >'/1"";7 All DATE EVALUATED
PROPOSED FACILITY % �%c PROPERTY SIZE
SUBDIVISION �'V�Lc� ROAD NAME
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut_
FACTORS
1 2 3 4 5 6 7
Landscape position
/—
Slope
Slo e %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
C
Consistence
!
Structure
�l
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
Landscape Position
EVALUATION BY: �ZZ
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 blockv 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
DCHD (01.90)
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