156-172 Fairfield Rd (2)Pemrittee's`'"' y COUNTY HEALTH DEPARTMENT
Name: '��i4'/�' f '`' P Environmental Health Section
c P.O. Box 848
.v
PROPERTY INFORMATION
Directions -to property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002571 A
Tax Office PIN:#
i.,,., _.
Road Name:1 ---
Lot:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any,.Buildin Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
—:17Office when applying fdr Building Permits.
(In compliance lith Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
_I I I'_`' I off' IS VALID FOR A PERIOD OF FIVE YEARS.
DATA ISSOED
RESIDENTIAL SPECIFICATION: BUILDING TYPE14I # BEDROOMS> # BATHS .2 # OCCUPANTS _�` GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ` r ' TYPE WATER SUPPLY 1 � UI ((DESIGN WASTEWATER FLOW (GPD}_ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE jGAL. PUMP TANKGAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER ! -D-IS TI (i'1 ti T1 q J
REQUIRED SITE MODIFICATIONS/CONDITIONS: ,
IMPROVEMENT PERMIT LAYOUT
1:5vV 1-jorAO I
f�
---rtVLJ
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 �O ZC 4J -Cz-f c_
SYSTEM INSTALLED BY:
AL
AUTHORIZATION NO. LS� OPERATION PERMIT BY: DATE: % 7L f!/
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DL9CRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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 07!02 (Revised)
. � �a
'Q
DAME COUNTY HEALTH DEPARTMENT
dame:. tli`"' 1t�' 1 ! 1'' i'' Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
"Directions to property: Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002571 A Road Name � �� � � � IL Ztp.� `f
**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 Forth/Authorization Number should be presented to the Davie County Building Inspections
Office when applying foFfiuilding Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900'Sewage Treatment and Disposal Systems)
•--"r _ !' , I _ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST` DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE i # 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 XJ01 tiDESIGN WASTEWATER FLOW (GPD) - 10 NEW SITE REPAIR SITE y
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH -� ROCK DEPTH `' LINEAR FT.
OTHER lI T 1 t,'J,C 1:
REQUIRED SITE MODIFICATIONS/CONDITIONS:
11 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. 1
OPERATION PERMIT
SYSTEM INSTALLED BY:
V /
AUTHORIZATION NO. S -71A OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM RIBED 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 02/02 (Revised) Q/C_t � <� ' / Z _ J z:f--
DAVIE COUNTY HEALTH DEP
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR
(Check One) REPLACEMENTp REMODELING ❑
N
Mailing Address: �% % U 2�_d IC 41 c IC/'LLt 76
Detailed Directions To Site:
Property Address:�r% � �r!l; i; r -L'
Ic��D�G
I
ENVWON17EN1At.11FAILTH
RECONNECTION ❑
Number: 3 `cp (0gd (Home)
i.� / — ,3'111(Work)
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: I 2)9,zw Q Type Of Dwelling:
Date System Installed(Month/Day/Year): _ ftC (-, Number Of Bedrooms: _f Number Of People:_
Is The Dwelling Currently Vacant? Yes ❑ No 21 If Yes, For How Long?.
Any Known Problems? Yes ❑ No V If Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of
Requested By:
Approved ❑
Comments
(Signature)
Of Bedrooms: Number Of People: 3
For Environmental Health Office Use Only
Disapproved Er-'
Pix T- t SSJ
X71 A
l --S Imo' ---gip
Requested:
Environmental Health Specialis ,!i Date `�ks—
*The
signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
eo
Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ JQ _Date: T.95
Paid By: ` Received By:( -
Account #: �I Z- Invoice #:
L _
gir(if� to of Compl � —•? >��} �__ late 9
'The signing of this certificate shall indicaTe�t—t system described above has been installed in compliance with
the standards set forth in the above regulaTon, but shall in NO way be taken as a guarantee that the system will function
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name ---Date ., _ N2 8033
Location �� `)- �J �y\ �;, -_ �� ,t�� :, `;� L' . i }
Subdivision Name
Lot No.
Sec. or Block No.
Lot Size' ' '
�' `'�'� House — Mobile Home
_'� --
Business --
Industry
No. Bedrooms
-- No. Baths No. in Family
--'
— Public Assembly
Other
Garbage Disposal
YES ❑ NO ❑'
Specifications for System:
Auto Dish Washer
YES p� NO ❑
�,�
,
Auto Wash Ma^hine
YES p' NO ❑
`
_�,
','
t
'�
!U• �
Y
of ,�•
3\_:..-:�:•
Type Water Supply
__ ,.
:`'
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. 1
i'
_ rC�i
Improvements permit by�--`_'`'-`
•Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
f-
H(S
",-,.Certificate of Completion �-_ —Date
'The signing of this certificate shall indicate that the system described ,above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
h'.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems _ Permit Number
Name _l,_ `.`r ::y".\-� �� --- Date a - }- 1 NO 803
Location
Subdivision Name
Lot No. Sec. or Block No.
Lot Size _ ' "
'`— House
—
Mobile Home "' -- Business —_ Industry
No. Bedrooms --
No. Baths —_--
No. in Family — Public Assembly Other
Garbage Disposal
YES ❑ NO
d1
Specifications for System:
Auto Dish Washer
YES ❑ NO
p
/
Auto Wash Ma^hine
YES. Q'� NO
❑
►
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
Improvements permit by --- --'
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by �� ^��s \��J�>Y_
L
41r;if�'
'The signing of this certificate shall indica'fe
the standards set forth in the above regula ion, bt,
satisfactorily for any given period of time.
Date 9 "-� - �f 5 _
above has been installed in compliance with
:en as a guarantee that the system will function
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE WT
Davie County Health Department k 7
Environmental Health Section
P. O. Box 665 MAY 15 1995
`"� 0- Mocksville, NC 27028
1. Application/Permit Requested By *&42r& 1C' - G
Mailing Address U : Home Phone /a �7
X70 A Business Phone
2. Name on Permit if Different than Above 0-
3. Application for: 4d General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House CIYMobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms r�i D/Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures .
7. Type of water supply: [/Public ❑ Private
8. Property Dimensions r� i Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Elmo`
If yes, what type?
❑ Community
`NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
Poo
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Ukf I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representativ#p.a�the Davie County Health -D partnt to enter upon above described
property located in Davie County and owned by ll4m 172r4 l( .j1�f / C
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
L;7 _ le' --q � Ei
DATE SIGNATURE
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation c
NAME ���� ��\xC� DATE EVALUATED
ADDRESS cS ix"Z�`R PROPERTY SIZE
PROPOSED FACIILTY �� ���- LOCATION OF SITE
Water Supply: On -Site Well _ Community
Evaluation By:C�-'-- Auger Boring Pit
Public
Cut
FACTORSWQ,
2 3 4
Landscape position
Slope 7f
HORIZON I DEPTH
Texture groupC
L—
Consistence
V—%. -
Structure
Mineralogy
HORIZON II DEPTH
2.
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
CLASSIFICATIONS,
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: 9—
REMARKS:¢
LE END
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
SILL -Silty :lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V+ ---y 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
3C --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(01-901
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�. j -" + f _ AV E COUNTY HEALTH DEPARTMENT
IiJamettee s *1'� ft�r� ;+ !� �` I. Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: t.;.1'' g `'' Miocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION NO: 002571 A Road Name: tM '- i L Zib: +:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any, Building Pennits. This Fortm/Authotization Number should be presented to the Davie County Building Inspections
Office when applying f6r Buildi'n'g Pen -nits.
(In compliance with Article I I 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.
ENVIRO MENT5A1?lit XIAH SPECIALIST DAT ISS D
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 w'#,�A `TYPE WATER SUPPLY �-�(�/► /DESIGN WASTEWATER FLOW (GPD)• _� A) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANKGAL. TRENCH WIDTH r•-! ROCK DEPTH 1 LINEAR FT.
OTHER IISTf if�'�..j(ai
;� .r• ,
REQUIRED SITE MODIFICATIONS/CONDITIONS: �t—�^t tit • i ••�`�
IMPROVEMENT PERMIT LAYOUT
t�t:.r�1TV
r ���� ���at,..t�z lt�.� S�,�ri✓1
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i
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r.}�,.►�..1 I cam' x'�;c.�., x I ��_. � 1�- ,G
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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
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 I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND.61SFOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
r.TTAAA?T=T7'rUATTLi0 CvcTCl.f 11111r rnr�rrrrr.�rn..r•n..•........... .. ....... .........._..___-__ ---