142 Horton Ln4-
Permittee's �tt DAVIE COUNTY HEALTH DEPARTMENT
Name: i- r-44�> Environmental Health Section PROPERTY INFORMATION
.0 7e) i -AW t ? P.O. Box 848
Directions to property: s Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
Ali ,-vv ZA% WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002631 A Road Name:1� +
� i%- �����C�►J �"�ip:.�7L��
**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 compliancl(vith�itie1111 of G.S�Fi'a
.'pter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
I ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
I A rf -T 'SPEOIALIST D E IS UED
ENVIRONME�I
RESIDENTIAL SPECIFICATION: BUILDING TYPEr'P- .# BEDROOMS # BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TY�PE` # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
B A&I,
LOT SIZWATER SUPPLY,/V �1DESIGN WASTEWATER FLOW (GPD) 5tPO NEW SITE REPAIR SITE /
SYSTEM SPECIFICATIONS: TANK SIZE `' GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH l2 LINEAR
OTHER , 2 C1► I, 1 &01 10ZDa6;S- r\CCePfCb Zn U U -y%— MAY hL &0
REQUIRED SITE MODIFICATIONS/CONDITIONS: I rjST^U--- (>JC1C CO , ` n
IMPROVEMENT PERMIT LAYOUT
D �
r
i
25�
106 110
" q
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
9 � f
AUTHORIZATION NOF:-21-7OPERATION PERMIT BY: /` zt-,eee4l DATE:
UTH
**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.
DMD 02M (Revised)
:ry i.. S 5 ,' p '- �.' (.i...:.. -. '411i. .F :.. h! 1 � . •'i .. t - _.. ,..1
Pe ' 's ' '''�4 = DAVIE COUNTY HEALTH DEPARTMENT
rnuttee �,•-..,,,,
Environmental Health Section PROPERTY INFORMATION
t
�Xr�rllp 7,} _-ty,l q P► P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
"`r 1 Phone #: 336-751-8760
r•l . �`,,j t. t��t rt '; ` ./�(rtir�` Section: Lot:
- J AUTHORIZATION FOR
- I ! � f1-16 l r` ,hI WASTEWATER -
( Tax Office PIN:#
SYSTEM CONSTRUCTION00263
-
' " AUTHORIZATION NO: 1 A Road Name:'�%{p:-..
**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 Pen -nits. 2
(In compliancel<vith Article 11 of G.S. C' Rapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
'***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
;;� ,•'-:r',��r , �''� (f IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL.HEi� SPECIALIST DA E IS UED -�
RESIDENTIAL SPECIFICATION: BUILDING TYPE i �Oy# BEDROOMS # B
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PtC
-f- ACR-- -`
LOT SIZE E WATER SUPPLY E"'� DESIGN WASTEWATER FL
2. # OCCUPANTS 5— GARBAGE DISPOSAL: Yes or No
(GPD)
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. lT�EN WI?'H _
OTHER � �_ 1 `7f, k LSV 1 w ,*.)
REQUIRED SITE MODIFICATIONS/CONDITIONS:►u--
IMPROVEMENT PERMIT LAYOUTCIZI, os
U /�L S ItJ o
# SEATS INDUSTRIAL WASTE: Yes or No
NEW SITE REPAIR SITE _
ROCK DEPTH ! 2 LINEAR FT-�
a
W40
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 Bi;,'
172'
u�D
AUTHORIZATION NO. OPERATION OPERATION PERMIT BY: DATE: '
**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 WI(L FUNCTION SATISFACTORILY.FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
Sow
FOR IMPROVEMENT PERMIT (REPAIR)
C
NAME i -AWL- PHONE NUMBER 7l2 -
ADDRESS Hy - 0()FTDrJ WIJ SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED 11-73 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY W NUMBER BEDROOMS �2- —NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �l-'AGt N!&
(o Moi . kgo
DATE REQUESTED I INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
&e4'.#3924
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #:
Billed To: �S
Reference Name:
Proposed Facility: Property Size:
PROPERTY INFORMATION
Tax PIN/ EH #:
Subdivision Info:
Location/Address: 1 �% Z 17k�yt7v4-) L -^i
Date Evaluated: ZZ -
Water Supply: On -Site Well / Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
SIC - Silty clay C - Clay
Slope %
CONSISTENCE
HORIZON I DEPTH
O -
Texture EroupGL
. FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Consistence
Structure
e
MineralogySzlcP
SP - Slightly plastic P - Plastic VP - Very plastic
HORIZON II DEPTH
Texture group
M - Massive CR - Crumb GR - Granular ABK - Angular blocky
Consistence
F. vsvp
Structure
ASk
Mineralogy
Lvy-
HORIZON III DEPTH
,ZO - 2(0
Texture Eroup
C-+ '0
Consistence
Structure
AS
Mineralogy
V -'i -Azb
HORIZON IV DEPTH
-r 1ES
Texture group
CLS-)
Consistence
Fe
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: �s<iGF Q'/l AUC/HA Mp
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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