127 Fairfield Rdr ,Penixittecj'sr j, DAVIE COUNTY HEALTH DEPARTMENT
. - Name JUS -f t +'t Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
t 1 % Section:
AUTHORIZATION FOR
WASTEWATER
Lot:
SYSTEM CONSTRUCTION Tax Office PIN:/#� p�- -
AUTHORIZATION NO: , 0 0 3 0 3 A R Z d Name:ir�/�Jd '` ' zip. i7:0
**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)
TLIIC A IT LIfAD17 A Tln%l C/\D ll/ A CTC\11 A TCD !`/%A10TnI T/-Tl/l11
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST bATEiSSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE ZNAE� # BEDROOMS # BATHS # 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) 36p; NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE qr-AL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH && LINEAR FT.
OTHER �V/tiLJ `LCI ;'6A
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
10
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ddf rw
IIFOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. I
r
OPERATION PERMIT
SYSTEM INSTALLED BY: CcA C in 'J !kW
box
c�A i��^ c�i5 I�a�' � CA
/17
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 02102 (Revised) :#� 511"5/ / `7191L
**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' ATE IS` SLED
RESIDENTIAL SPECIFICATION: BUILDING TYPE. # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE . TYPE WATER SUPPLY(ry A 1<U DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE " '!AL. PUMP TANK GAL` TRENCH WIDTH b ROCK DEPTH LINEAR FT. /
OTHER /;�� ff t�a� 4I r 6 r�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT h
s�►nS -- _ _ few
_
USE
Si
h
r� , /� '��
VS
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. T �p� F INS 4LATION. TELEP i ONE # IS (336) 751-8760.
OPERATION PERMIT(( n l
SYSTEM INSJ�LLED BY,�" ,!�' 1 'J , = (J N F� / QO� r r i�
A L\ -
c.hUU1 h \3 1--
7
14—
�4
'r -e-GJ 6-1 � 5Y.514,
AUTHORIZATION NO. OPERATION PERMIT BY: �o �" ' �""_ DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
11
WITH ARTICLE I 1 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 02/02 (Revised)
���:�Perritteo',DAVIE
COUNTY HEALTH DEPARTMENT
Naipo: ', f S4!I I\ U
��D!) Environmental Health Section
PROPERTY INFORMATION
P.O. Box 848
k
Directions to property: >
/ Mocksville, NC 27028
Subdivision Name:
... _ 1. _
Phone #: 336-751-8760
••
'`�`'�,
Section.
Lot:
AUTHORIZATION FOR
i
'
WASTEWATER
Tax Office PIN:#
- -
SYSTEM CONSTRUCTION
� �f
Tczip.Z70Zk
AUTHORIZATION NO:
0030113 A
Road Name
**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' ATE IS` SLED
RESIDENTIAL SPECIFICATION: BUILDING TYPE. # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE . TYPE WATER SUPPLY(ry A 1<U DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE " '!AL. PUMP TANK GAL` TRENCH WIDTH b ROCK DEPTH LINEAR FT. /
OTHER /;�� ff t�a� 4I r 6 r�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT h
s�►nS -- _ _ few
_
USE
Si
h
r� , /� '��
VS
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. T �p� F INS 4LATION. TELEP i ONE # IS (336) 751-8760.
OPERATION PERMIT(( n l
SYSTEM INSJ�LLED BY,�" ,!�' 1 'J , = (J N F� / QO� r r i�
A L\ -
c.hUU1 h \3 1--
7
14—
�4
'r -e-GJ 6-1 � 5Y.514,
AUTHORIZATION NO. OPERATION PERMIT BY: �o �" ' �""_ DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
11
WITH ARTICLE I 1 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 02/02 (Revised)
u
NAM
��us4iee_-,
ADDRESS
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
&A�PHONE NUMBER
DIRECTIONS TO
s
S�
UBDIVISION NAME
LOT #
IAJL e_ -1 -w-
" -V oIVA iFAL4 -id U
DATE SYSTEM INSTALLENAME SYSTEM INSTALLED UNDER XqfAiqrd&Md d -
TYPE FACILITY& NUMBER BEDROOMS NUMBER PEOPLES SERVED
TYPE WATER SUPPLY. &U SPECIFY PROBLEM OCCURRING bl -0T Mid,
,
&/2 f, Al ch t1d i IVI-Iii �J, 67 N 1W -l( ZYM, (A MUM
DATE REQUESTED �! l0 INFORMATION TAKEN BY,
This is to certify that the information provided is correct to the best of my knowledge, and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
juS} Ct
I0-0 I-Vlr te`d 6
kocy-13U0C )Uc PWS
PROPERTY INFORMATION
Water Supply:
On -Site Well
Community /�
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope % e
HORIZON I DEPTH
Texture grow
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: r)
LONG-TERM ACCEPTANCE RATE: .3
REMARKS:
LEGEND
EVALUATION BY:
OTHER(S) PRESENT:
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
MQLq
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
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
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 05105 (Revised)