126 Casa Bella Drive Lot 17Permittee' 'h _ 1 • , ,,,WIE COUNTY HEALTH DEPARTMENT
-Name*.. tp Lrt�ni ��1.. Environmental Health Section PROPERTY INFORMATION
!' P.O. Box 848
Directions to property. °' l .Cay/ 1.—I=' �- Mocksville, NC 27028 Subdivision Name:T lam'
Phone #: 336-751-8760
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AUTHORIZATIONASTEWAER OR
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SYSTEM CONSTRUCTION Tax Office PIN:#CAP-
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AUTHORIZATION NO: 002632 A Road Namet i--') ` 1 "' 2—
21 C
**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.
(ln compliance with Article -I 1 of G.S. Cha�te(� 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
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***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
A HEAI/' ISPECI UstP SD
RESIDENTIAL SPECIFICATION: BUILDING TYPEIJAVJAW BEDROOMS 1-1—# BATHS 2 # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT' '# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 'NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �/L/ ROCK DEPTH K% LINEAR FT. l
OTHER RLrF-9tj4; ,J6 FLOW VAI--yC:- ��'�►t� . 2sr�o R�: �TIo.J S�S-K:-�.�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT "
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT i't t 5L 1p ��� A 1�� � • ` �`--v'
SYSTEM INSTALLED BY: �`'tNY.� ►vim
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AUTHORIZATION NO.OPERATION RMIT BY: v (:—IVDA:_
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"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE TH HE SYSTEM SC E BOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1909 TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BETAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN, PERIOD OF TIME.
Dail) (Revised)h6C # 9741-ZVV01� : -- -13 -7
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Ptcee'" £' _�` Y , DAVIE COUNTY HEALTH DEPARTMENT
. �Tartiei``~L.F1 YVL.1.3 Environmental Health Section PROPERTY INFORMATION
=' P.O. Box 848
Dire&4gps to property ^''- ! '" '} Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
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Section: Lot:
-4..�.. {VL' AUTHORIZATIONEWA.R OR
I t Tax Office PIN:# -
SYSTEM CONSTRUCTION
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AUTHORIZATION NO -D 2 i i..At< Y '. l_�
y_ 2 e f tp. -4 C11
**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 1 of G.S. Ch pter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
~
- t , ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
It
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL {FAUN SPECIALIST. DAT ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE wig"# BEDROOMS # BATHS 2 # OCCUPANTS `�- GARBAGE DISPOSAL: Yes or No
'i -
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT' # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY .tC�y
DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3V ROCK DEPTH A LINEAR FT.'L-�-/
OTHER KL1-cVA-6,-IJb 'FLL)W VAt-1 -
REQUIRED SITE MODIFICATIONS/CONDITIONS:
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT ff I s I �-
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SYSTEM INSTALLED BY:
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AUTHORIZATION NO. 2-0", OPERATION RMIT BY:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE HE SYSTEM
WITH ARTICLE 1 I OF G.S. CHAPTER 130A, SECTION .19 E TREATMENT.AND
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN
,y
DCHD 021W (Revised)
`% Nk I L..t.l.K
RAN VF
SCWED7BOVE HAS BEEN INSTALLED IN COMPLIANCE-.
DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
PERIOD OF TIME.
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' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #:
Billed To: ( )JL..,4 I�
Reference Name:
Proposed Facility: Property Size:
PROPERTY INFORMATION
Tax PIN/EH #:
Subdivision Info:
Location/Address:
Date Evaluated: c`_7
Water Supply: On -Site Well Community Public y
Evaluation By: Auger Boring Pit 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
Landscape Position
EVALUATION BY: _ tew &_A(,C4411f_1
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
ONSISTENCE
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
DCHD 05/99 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Cell- &5 ��L3
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) Q G
NAME Oreqft'fl lJO U (WA1201i W 17m ll V?l Pl ONE NUMBER
ADDRESS dasa&llel A7. d-d-11dowe- SUBDIVISION NAME
/ LOT #
DIRECTIONS TO SITE �O �• ��r�VlgiZe Q 0
Z,W 21J4' Lz-Al sgelltq
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY W f7 NUMBER BEDROOMS "3 NUMBER PEOPLE SERVED
TYPE.WATER SUPPLY SPECIFY PROBLEM OCCURRING bail
A AOf I
DATE REQUESTED INFORMATION TAKEN BY,
This is to certify that the information provided is correct to the best of my knovKledge, and
SIGNATURE OF OWNER OR AUTHORIZED
Rev. 1193
charges incurred from this application.
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