121 Frost Rd (2)Permittee's / DAVIE COUNTY HEALTH DEPARTMENT
Narne:• s � �� I+\1 �: 6 ��� Environmental Health Section PROPERTY O A N Q
4P.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: 5 A Road Name T -I . ,1 1 �� r Zip: = "
**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 bavie County Building Inspections
Office when applying for Building Permits.
(Incompliance wit Article 11;'of C3,,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 SPECKLIST DATI! ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE —, , # BEllROOMS # BATHS # OCCUPANTS 1' GARBAGE DISPOSAL: Yes or No
r
COMMERCIAL SPECIFICATIONN: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: YesorNe
LOT SIZE-' PE WATER SUPPLY ( C>Ot`'r
DESIGN WASTEWATER FLOW (GPD)`"(-� NEW SITE REPAIR SITE V
F
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �►° r ROCK DEPTH 1 Z-" LINEAR FT. :tJ
OTHER <—
REQUIRED SITE MODIFICATIONS/CONDITIONS: t 'Off-
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IMPROVEMENT PERMIT LAYOUT
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**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 (336)751-8760.
OPERATION PERMIT /y
SYSTEM INSTALLED BY: l i
CP
4 Lfl S
AUTHORIZATION NO.0� A OPERATION PERMIT DATE: I '
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS DESCRIBED ABOVE H EEN INSTALLED IN COMPLIANCE
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)
D+ (� �/] IPP ON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
---�t�t� V �-C Davie County Health Department
__ Environmental Health Section
2004 P.O. Box 848/210 Hospital Street '
Mocksville, NC 27028
(336)751-8760
do��—
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IS AP LICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORM ,3'i0R"IS—TROVIDE Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed ( A QLI, Contact Person 2 Q 0
Mailing Address 12 G -- C S l 12 CII � Home Phone 3 +J% (o
City/State/ZIP A6J,/C1:'1CC N�- ���70��O Business Phone 7_1:3 n 3
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
R
3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both
4. System to Service: A House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. Type system requested: Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People I # Bedrooms # Bathrooms
7.
I tDishwasher ❑Garbage Disposal PWashing Machine
If Business/Industry /Other: verify type
# Commodes
# Showers
IF FOODSERVICE: # Seats
❑Basement/Plumbing ❑Basement/No Plumbing
# Urinals
# People # Sinks
# Water Coolers
Estimated Water Usage (gallons per day)
S. Type of water supply: /i�, County/City 13Well ElCommunity
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0 No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:"
Tax Office PIN: #
Property Address: Road Name 0 5 d
City/Zip / / J ✓ca nc'
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
1
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Date home corners flagged:
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 ant responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Departme t
to enter upon above described property located in Davie County and owned by ao✓ Su 7 c n a <- /uxe k )4_
to conduct all testing procedures as necessary to determine the site suitability. �—
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DATE a �U� `-1- SIGNATURE z -
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
CS S 4-e-� , n S �-' '.. / w -r-"/- Y a's ) Site Revisit Charge
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Date(s):
�0 — o--- rlient Nntificstinn Date:
1-120 Ir fl -0 d ��
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Sign given ,-to
Revised DCH (05/03
EHS:
Account No. �3,3- / /_
Invoice No. 3 O
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PSrmit?ee's r r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
i P.O. Box 848
Directions to property: 1 Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
r» � � Y i 'j
AUTHORIZATION NO: 0026` .) A Road Name: ( � .: # Zip: —
"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.
L'HEAI TH;SPECIALIST DAII•E ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPEI.' t ?:�# BEDROOMS > # BATHS –j— # OCCUPANTS' GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE � -, .': r -t'' Y1E WATER SUPPLY .t rt �i�DESIGN WASTEWATER FLOW (GPD) 's - 0i' NEW SITE REPAIR SITE
i w ' 7'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH v% ROCK DEPTH �^ LINEAR FT. / -f --
,
OTHER ? �_ '- �E � '-�;t� L , )L " /0,j �� i�Pv'� r�`iL'i;- fi•��yi/o"�, •d T-
7 -f C.))
REQUIRED SITE MODIFICATIONS/CONDITIONS: � j.
IMPROVEMENT PERMIT LAYOUT
IVI
ASStgl,
�I 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. N
OPERATION PERMIT N�
T I TALLED BY:
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ion
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AUTHORIZATION NO.. y% OPERATION PERMIT BY: TE: l �"p
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEMtDES A BEE STALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT ANDYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OP%(r2 (Revised)
i
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
� '16 ms 121 Froaf 1'cl
�2X �
Water Supply:
On -Site Well
Community
Public X
Evaluation By:
Auger Boring �_
Pit
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Slope %
m
HORIZON I DEPTH
Texture group
Consistence
LZ
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
Ps El
LONG-TERM ACCEPTANCE RATE
F
SITE CLASSIFICATION: S
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
EVALUATION BY: &tJU 60kM,,
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
1/ =1
VFR - Very friable FR - Friable . FI - Firm VFI - Very firm EFI - Extremely firm
M
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)
TTAR-T.nnv_term arrrntnnrr rate - oal/rlav/ft) Tl%f Tm Acing rr,___e_ _ ..