151 Grassy Cove Trail' .
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�~�~^ COUNTY ^ ^^�^��^^^ DEPARTMENT
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IMPROVEMENTS PERMIT AND ,CERTUFUdATE OF COMPLETION
|nmumdipCompliance With Article UofG.S. Chipter130a -' \
Sanitary Sewage Systems
^ Nome Date
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-A^�.
Subdivision Name Lot No. Sec. or Block No.
Lot p/�e X House -_-___-_Mobile nmxe.-__`-_---Business _-____-_Speculation
-___-___
No. Bedrooms .No. Baths No. in Family
�
Garbage Disposal YES uu / Specifications for System:
[] NO
Auto Dish Washer YES 0' NO[]
Auto Wash YWo:h}ne YES NO
Tvoa Water Supply
*This permit Void ifsewage system described below io not installed within 5years from data of issue.
This permit insubject torevocation ifsite plans orthein1endeduoaohange.
-- permit by
*Contact m representative o/ the Davie County Health Department for final inspection of this oyobam between 8:30-
9:30 A.M. or
:3O'9:3OA.K4'or 1:00'1:30 P.M. on day of completion. Telephone Number 704'634'5985.
_ .
Final Installation Diagram: System Installed by
. � �
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' CedUficabmofCompletion Data
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth inthe above regulation,butmha||inNOwoybatakanooaQuaranteathadthenyotemwiUfunotion
satisfactorily for any given period oftime. -
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section J� ,
P. O. Box 665 - I
Mocksville, NC 27028 `
1. Application/PermitBy=A1^1'� G - e!Y, ���
R(e�quested 1,
Mailing Address �1 �+� � �t� 16—" ,0� e_-,
Home Phone %0 4 ~ 4 Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve: m House
❑ Business /❑l Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
❑ General Evaluation
❑ Mobile Home
❑ Other
No. of Bathrooms
—
Dwelling Dimensions 3D X
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
Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
l� Washing Machine
Dishwasher
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply:] Public ❑ Private ❑ Community
8. Property Dimensionsl � )L `;? f t? Sewage Disposal Contractor ae 00 Ci,d 2!jS
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No
If yes, what type?
'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: /-5
This is to certify that the information provided is correct to
incurred from this application.
DATE
my knowledge, and
responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. I OWN the property. ❑ 2. I 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 representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
\ Soil/Site Evaluation
NAME _ Y., RN Wt"V -P'_ DATE EVALUATED - a
ADDRESS S Ccs PROPERTY SIZE loo, a 0 I'
PROPOSED FACIILTY o V SAL LOCATION OF SITE O�S
Water Supply: On -Site Well Community Public 1�
Evaluation By:Auger Boring ✓ Pit Cut
FACTORS
1
2
3
4
Landscape position
S
S
s
----5
Sloe %
b-
- s
HORIZON I DEPTH
"
a
''
I
Texture group
C' L
L
Consistence
I T1
FT
ip T_
Structure
C
Mineralogy
'1
'1
HORIZON II DEPTH
`D.
h
s r
Texture groupC
'.
Consistence
"-
Structure
pk
Vk%'r
IV,,
MineralogyL;
1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
SS
RESTRICTIVE HORIZON-
SAPROLITE
—
—
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: Q
LONG-TERM ACCEPTANCE RATE: •
REMARKS:
DCHD(01-901
EVALUATED 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
Moist
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
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AUTHORIZATION NO: 1801 DAVIE LINTY HEALTH DEPARTMENT
v Environmental Health Section PROPERTY INFORMATION Permittee-s P.O. Box 848
Name:+ ' Mocksville, NC 27028 Subdivision Name:
Phone # 336-751-8760
Directions to property:Section: Lot:
AUTHORIZATION FOR
WASTEWATER
Tax O
SYSTEM CONSTRUCTION Office PIN: ! .
Road Name: Zip: d .
**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
Officewhen applying for Building Pen-nits.
(In compliance with Article .l 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) `
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
,I :� r ✓ f' IS VALID FOR A PERIOD OF FIVE YEARS. 9
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
*'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
�' 'SYSTEM INSTALLED BY:
<r't
*'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
�' 'SYSTEM INSTALLED BY:
�l
tu
1 �y� APPLICAInON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ^ �
Davie County Health Department
Envlrwnmenlal fleaft SeWOJ7 J
P.O. Bos 848/210 Hospital Street
Mocksville, NC 27028
e (336)751-8760
***DJP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. game to be Billed L-4, Contact Person
Nailing Address �tj 1 'gcog /����! ,� Same Phone tS 'Y y 4 1
City/State/ZIP ,�S ,`l�?O !�/J�. Business Phon rA5W-'— 7:2 9-1/
2. Name on Permit/ATC if Different than Above
Nailing Address
City/state/Zip
3. Application For: IA'Site Evaluation 0 improvement Permit/ATC 0 Both
4. system to service: a House 0 Mobile Home 0 Business 0 Industry 0 Other
a. If Residence: # People # Bedrooms -3_ # Bathrooms
0 Dishwasher 0 Garbage Disposal J:~hing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # sinks
# Commodes # shovers # Urinals # Nater Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: a-dounty/City 0 well 0 Comounity
e. Do you anticipate additions or expansions of the facility this system is Intended to serve? 0 Yes 0 No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: h9e WRITE DIRECTIONS (from MockrAlle) to PROPERTY:
Tai O 0 d
ffice P[N: x #1� %�� �13 ^ l�� �, 8 bo��
Property Address: Road Name
City/Zip o? 70 0Z 7
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
Date Property 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 am responsiblefor all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
/////,�i�i%
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).
Revised DCHD (07/98)
Account Na
Invoice No. '�)/+/
_, •;.� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME L`'y
PROPOSED FACILITY l
SUBDIVISION
Water Supply:
Evaluation By
On -Site Well
Community
Auger Boring ✓ Pit
DATE EVALUATED f��0
PROPERTY SIZE
ROAD NAME
Public 4---_J
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position A G
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH f
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 7
SITE CLASSIFICATION: / EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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 Sl - Silt ,
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
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 (01-90) -
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT w� -
NAMEy SCS 171,-,. 1/ f -S PHONE NUMBER11f #� �7� ism 7;79
ADDRESS ,/2vr- /tee r/'4 SUBDIVISION NAME
SUBDIVISION LOT #
DIRECTIONS TO SITE eircC 7L��✓1 O J
s-1,,cc - an
se,
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
/2/V op to /741W'E' 4Qr600a-1 /OlJlGf�1 �`'eit /- 75-
oGn `�' 'S'✓ �C�.
CJ /I' �/� � liS7L / ✓J ter. <i� ��