433 Gladstone RdPermittee's --'" OUNTY HEALTH DEPARTMENT
Name: - ,=:.c�"!`w t'.�r'�'�7 Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
r
Directions to property:
Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760
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Section: Lot:
AUTHORIZATION FOR
WASTEWATER
Tax Office PIN:#,,�
SYSTEM CONSTRUCTION
41 3 /74 5 on
AUTHORIZATION NO:
0 Q 2 G. ., *
A
Roa Name: i'l4nwlfe ��; //,Zip: Z 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
,i
s" / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r.l 6U�! r" /R' e' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE H # BEDROOMS 9 # BATHS 0-1 # 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) NEW SITE REPAIR SITE
i I
SYSTEM SPECIFICATIONS: TANK SIZE AM. GAL. PUMP TANK GAL'. TRENCH WIDTH ~� ' ROCK DEPTH � LINEAR FT. %
OTHER '
%:ri °.it::tij lit 1 'vv v .f� h: FISP,
REQUIRED SITE MODIFICATIONS/CONDITIONS:CCeptt:d Systeme. mP
IMPROVEMENT PERMIT LAYOUT
II 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:
AUTHORIZATION Ne%� OPERATION PERMIT BY:DATE: C O
**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.
xHD 02102 (Revised) 1 / 1ejrwL q/0 x _100 Y 0
._'i Permittee's ,�' �� Y OUNTY HEALTH DEPARTMENT
11Vam�'l" c"' :3 <;'• .' ° 1•� Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property.--, Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: _ _ Lot: z
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
x� -� /<N. Z�0 zh
AUTHORIZATION NO: 0 0 � �3 A Road Name: ,Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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 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.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE H # BEDROOMS --Q—# BATHS c = # 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) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH b ROCK DEPTH i__-� _ LINEAR FT.0
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
o
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. u
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION N � OPERATION PERMIT BY: DATE:
/`/ D
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 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.
D 2 (Rev;ua) �� # /Wo
previous,
0W Ntr2. Sim tB 0
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME Lv/w IV PHONE NUMBER oCd 7 a�
ADDRESS P.O .&A /N A00 o lle A/6' SUBDIVISION NAME
/7 33 gZds)je, /fit LOT #
DIRECTIONS TO SITE _& 6 aLdIdIye d 2
h -a -w'V33
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
Gt e ./Mede 4- �'yIe G{%//air
DATE REQUESTED ��D� INFORMATION TAKEN BY (�
This is to certify that the information provided is correct to the best of my
SIGNATURE OF OWNER OR AUTHORIZED AGENT.
Rev. 1/93
and that I understand I am responsible for all charges incurred from this application.
/J A n e
f DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: Tax PIN/EH #:
Billed To: Subdivision Info:
Reference Name: Location/Address:
Proposed Facility: Property Size: Date Evaluated:
Water Supply:
Evaluation By:
On -Site Well v Community_
Auger Boring Pit c/
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
ell
Consistence
V
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
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: %f `
LONG-TERM ACCEPTANCE RATE:
REMARKS:
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
oist
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
DCHD 05/99 (Revised)
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