133 Gordon DrDAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street n l 1
Mocksville, NC 27028 (1/a
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005655 Tax PIN: EH #: 5862 -34 -5619 -SOLD
Billed To: Larry Cornelison Subdivision Into:
Reference Narne: REPAIR PERMIT - New Owner LocationrAddress: 133 Gordon Drive -27006
Proposed Facility: Residential - Repair Property Size: 1.09 Acre
ATC Number: 5755
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been 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.
f System Type: ' ' S.T. Manufacturer N/A— Tank Dateank Size Qd
Pump Tank Size L/
System Installed By: 5�-eiWt-G H u E.H. Specialist: VZt;ate: Ll
GPS
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DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005655
Billed To: Larry Cornelison
Reference Narne: REPAIR PERMIT - New Owner
Proposed Facility: Residential - Repair
Tax PINIEH #: 5862 -34 -5619 -SOLD
Subdivision Into:
LocationrAddress: 133 Gordon Drive -27006
Properly Size: 1/* Acre
-"T '1'1JV�%i 5IP55Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS IP/ AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
oar the intended use change. ^t
Residential Specifications: # Bedrooms # Bathrooms People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Size .Q ( C /R- Type of Water Supply: bounty/City ❑Well ❑Com unity Well
((SS s
System Specifications: Design Wastewater Flow (GPD) ��Tank Size C� aL. Pump TankGAL40.
a
Trench Width 3 li Max. Trench I)epth 3 � ( Rock Depth_,r i Linear Ft. /000 0 Gc le
cc a in l ; , f 57A t'OLC[.c-f `0 L,
Site Modifications/Conditions/Other:--f'---` r : ,r
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)753-6780.
li
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
3 3 Er,j ova iQ
til C_ `l --(a d C
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
Community
Pit
,PROPERTY INFORMATION
Public /
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe %
HORIZON I DEPTH .-
Texture groupG
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 T 41
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
EVALUATION BY. of s6/ zd�C-�
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
rkVj M, M
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
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 05105 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
PHONE NUMBER 9"77-6 33 4 C
ADDRESS 1 3r3 C,,,(c9-SUBDIVISION NAME
RaOO,LA-c-e /U C LOT
DIRECTIONS TO SITE :t It a _� � l'1 � ( Al L16
�r8c�,,t '
t 3 3 d41 L_
DATE SYSTEM INSTALLED lq q 6 s NAME SYSTEM INSTALLED UNDER d
TYPE FACILITY -'5 F NUMBER 13EDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �O l ` SPECIFY PROBLEM OCCURRING i -� -E Sefd UJ
IF
DATE REQUESTED 3 l C) INFORMATION TAKEN BY D to,(�Cl%r: _e S
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 & i # v,
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