148 Sonora Drive Lot 9A xi?Riz TION NO. DAVIE COUNTY HEALTH DEPARTMENT
'Environmental Health Section PROPERTY INFORMATION
Perm}ttee's'L t r P.O. Box 848
Name; ` Mocksville, NC 27028. Subdivision Name:
Phone #:704-634-8760_.
Directions to property: t Sf�r1 �1"rN'��, Section: Lot:.
AUTHORIZAITON FOR
WASTEWATER Tax Office PIN:# 'i!Y !7 �_ .
SYSTEM CONSTRUCTION f
j %
Road Name: 0t/ r ' Zip. �Q
**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. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r ***NOTICE**.* THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
•�S IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL'14EALTH SP IALIST. DATE ISSUED
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r 1071 DAVIE COUNTY HEALTH DEPARTMENT
�
Al ` IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
r.Natvp Subdivision Name:" .,/�
-Mieict ns to property:;; x t R/r%. Section: Lot:
E1lPROVEMENT
PERMITTax Office PIN:# i l7
Road Nam ode �Zip ;
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
,� � ,y •,� , . � .io `; �,�, j, � , ' �:�'= : • a _,! 1' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ,: ,
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE' M.
SYSTE
RESIDENTIAL SPECIFICATION: BUILDING TYPE / # BEDROOMS � # BATHS �s�-- # OCCUPANTS_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPES # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No .
LAT SIZE TYPE WATER SUPPLY. ` DESIGN WASTEWATER FLOW (GPD) NEW SITE C� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 9- GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH f G1 LINEAR FT, J
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"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. ;
AUTHORIZATION NO. (( OPERATION PERMIT BY: DATE:
t • ' APPLICATION FOR SITE EVALUATIONAMPROVEMENT
Davie County Health Department Q
a p
Environmental Health Section
P.O. Box 848 SEP 1 71997
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed v%GY Contact Person
Mailing Address . � d 7 & W C!�o / '5' / 1 Home Phone 99g:
City/State/Zip Itl e Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address � %y Y City/State/Zip eZ--t/j 14/6 -
3. Application For: [V]'Site Evaluation [.+T provement Permit & ATC [•-]'Both
4. System to Serve: [ ] House V,11A-obile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People,3 # Bedrooms,,7 # Bathrooms^.Dishwasher [ ] Garbage Disposal
[1].Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [bounty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes V -].lo
If yes, what type?
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PROPERTY INFORMATION REQUIRED: *** IMPORTANT **J*0&)F%AT OF THE PROPERTY MUST BE
F ,, /S �/ r-�' SUBMITTED WITH THIS APPLICATION.
Property Dimensions: /0 7 �l `�' R X / �J WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #,6'970 - 3 - 41277 �/a ;n J -C: I r N -C- - -77 bG71 ate+
Property Address: Road ame Snn/ Deli Dr,--,, i✓c na Dryy 04d % Sd e4
City/Zip Aja,4nec. -77o04 /os %%e•,tiG - �n�� Lc�/( ,
If in Subdivision provide information, as follows:
Name:
Section: Lot #:
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 County Health Department to enter upon above described property located in Davie County and owned
by
DATE ����0 C/ -7
Revised DCHD (06-96)
all testing procedures as necessary to determine the site suitability.
THIS AREA MAY $E USED FOR DRAWINQ YOUR SITE PLAN:
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION�LOT
Soil/Site Evaluation
APPLICANT'S NAME 6,_,f ZB✓'
PROPOSED FACILITY %%%i Zt.
SUBDIVISION al 0 (/y 4 Ile -
Water
Water Supply: On -Site Well
Community,
Evaluation By: Auger Boring Pit
DATE EVALUATED
PROPERTY SIZE ,A0d X 5_D
ROAD NAME :5&/701W _
Public z/
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
,L
Slope %
02
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
3G 1 -
Texture rou
Texture
Consistence
i
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
t
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: i
REMARKS:
DCHD (01-90)
EVALUATION BY: �/ ,
OTHER(S) PRESENT:
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
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