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Wig IN
AUTHORIZATION NO
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�- .. DAME COUNTY
Pe rcm A r
EnvirontneiEALTH DE
Name: "�` R'rj� R `A
nillimth 1�1 NT'
Directions to ME
NT'
P.0 $pX 848—
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SeCtlOn
._... onksville, N�
One #: 028 FRTy1NF
ti 704_
r, AUTNO 634-876p Subdivision Name: .. OATION
**NOTE**`This
Au SYST M c N�'A70ER �R Section;
to isffisuan a°nation for �y STRUUTI�N
(In co � Ice Whena any Bp�din r SYste Tax OfRce . ' Lot:
mph'ance with PPIYin 9Permits m Cons . IN;#
Article 1 j of °i Buildings This FO Auuchcn QST Road Na �2d
B1�ry1R r G.S.ChaPter 13 p �'asw th°r,Zation Number SUED 6Y theD, me.�'�`�
.�
sho D �-
oNNtB AL t1EALTy spEcr *r*r SYsterns, Seco vil.1 be Presented to the DaVnV �On'nearal
AL IST DAT U D�.� *NOTICE*** THIS A ewage Treatment arta Dis °unt3' Bai d g ect io oPs °r
E ISS
IS VA.CZ A TION POR WAS Posal SYsterns)
RIOp OF�TER CONST
RU ON
�!'E iY M.d � °-� y" s... xe,y-•• .Cr s'�t• kA t.. Phar ip y�4hM_y:.r'���n+"��"'rr'-R'y `v''"�'.,� � e' � i :'! '; ,. , �:• i
n?
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittees � ,� ,.,�' �
l�jam Subdivision Name:
Directions to property:,,"�.>�' - Section: Lot:
IMPROVEMENT
zl—
`PERMIT Tax Office PIN:#Mle- + r
�.»)
Road Name: .) < Zip:
**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 lS 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 _:2-- # OCCUPANTS �? GARBAGE DISPOSAL: Yes or No
COMMERCIILL
ASPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE /SWXE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �W NEW SITE G'� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE,—j26 GAL. PUMP TANK GAL. TRENCH WIDTH �Y ROCK DEPTH A0 LINEAR FT.
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 (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
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)
---" DAVIE COUNTY HEALTH DEPARTMENT
+' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
tT ' ~Permlit&'S� * f %+ ) :P �r`r.�"
,--Nam; �- ,��.+ f�7 �' �`_. .��1 �. Subdivision Name:
�r
Directions to property: Section: Lot:
IMPROVEMENT
�1r
PERMIT Tax Oce PIN#
'
Road Name: o4 i *#=` Zip:
**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 LS 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.
- V.. .
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS_ # OCCUPANTS r GARBAGE DISPOSAL: Yes or No .
t„
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS ' INDUSTRIAL WASTE: Yes or No
L SIZE''FTYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) '`' NEW SITE �/'� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE, /7,'),f GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. / ✓S
A
:OTHER
'-
REQUIRED SITE MODIFICATIONS/CONDITIONS:
OPERATION PERMIT
SYSTEM INSTALLED BY: `
.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)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760
J
****IMPORTANT****
1. Name to be
Mailing Address
City/State/Zip:
OCT 3 01997 D
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED._
Contact Person 41111-Vb
46(11, 0 d4 t, Home Phone 2 �/
/ /G'• / Business Phone �`�l1 02 c3 LJd
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [ ] Site Evaluation
City/State/Zip
[ ] Improvement Permit & ATC W1 oth
4. System to Serve: [ J House [prMobile Home [ ] Business (] Industry
5. If Residence: # People # Bedrooms --'9# Bathrooms_
gashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People,_#Sinks # Commodes
[ ] Other
[ ishwasher [ ] Garbage Disposal
7
8
# Showers # Urinals # Water Coolers
If Foodservice: # Seats"' �kstimated Water Usage (gallons per day)
Type of water supply: ount/City [ ] Well [ ] Community
Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes
If yes, what type?
[ ] No
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ** �MJ?ORTANT *** T OF THE PROPERTY MUST BE
6- 34 4F / SUBMITTED WITH THIS APPLICATION.
Property Dimensions: p WRITE DIRECTIO S (from Mocksville) TO PROPERTY:
Tax Office PIN: # O - _� -
Property Address: Road )am '�
'I
city/Zip
If in Subdivision provide i ormat&nollows:
Name: W'
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
(/ SIGN
Revised DCHD (06-96)
THIS :' ':A AtAy $E USED FOR bRAWZNCC YOUR SITE PLAN:
as necessary to determine the site suitability.
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00
N C)� O6'
K)l
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT O
Soil/Site Evaluation
APPLICANT'S NAME �c�'/' DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION �yl'�f%�//%✓��V ROAD NAME��'l/9'��
Water Supply: On -Site Well
Evaluation By:
Community,
Auger Boring Pit
Public v
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe % <..
HORIZON I DEPTH
Texture group
Consistence Z
Structure
Mineralogy
HORIZON II DEPTH 77
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:
norm (ol-vo)
EVALUATION BY: A4,1f'
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
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