1798 Hwy 801SPermittee'/ D VIE COUNTY HEALTH DEPARTMENT
Name: �' Environmental Health Section PROPERTY INFORMATION
-10 � c l P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
r _t (c �� ��it�l Phone #: 336-751-8760
Section: Lot:
r AUTHORIZATION FOR
C WASTEWATER
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 00209 15 A
Tax Offi e PIN:# - -
/ 70 h LL. _-.
Road Name: i `� G - 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 1 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 !� r.-- # BEDROOMS �_ # BATHS I # OCCUPANTS -:)_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT 4FSEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE � �i SGAL. 'PUMP TANK AAL. TRENCH WIDTH ROCK DEPTH t; LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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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 BY: 4-- Ci's :j / r%h -e—
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AUTHORIZATION NO.�OPERATI N PERMIT BY: � 2 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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
A;
D VIE COUNTY HEALTH DEPARTMENT
t Environmental Health Section PROPERTY INFORMATION
cfiL P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
f Phone #: 336-7$1-8760
Section: Lot:
y AUTHORIZATION FOR
1
! i . / a WASTEWATER -
SYSTEM CONSTRUCTION Tax Office PIN:# -
17
AUTHORIZATION NO: 002915 A Road Name:—I �6; l J Zip: ^� �• r'�
**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
0 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS_ # BATHS I # OCCUPANTS —_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY �V DESIGN WASTEWATER FLOW (GPD) / " NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE ( SGAL. PUMP TANK _LL/AAL. TRENCH WIDTH J ROCK DEPTH G , LINEAR FF.
_
OTHER `U tit►
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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IG 5 y
r,.
• �YwSc 7/Gl'ST � r'
I
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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 BY: _ L a!611 5 �Uh
L��-F ao ChaweIL-Le rs
a 2�
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AUTHORIZATION NO. 5— OPERATI N PRMIT BY: �� �� DATE: e2
**THE�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I f OF G.& 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.
�(1r
KD �2,aw(Revised)
Po Box /aZ
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME I /umit UOgI�� PHONE NUMBER *P - f45(
ADDRESS I qqf Ne HWV �0I S AdCON'ee /VCS SUBDIVISION NAME
DIRECTIONS TO
in
LOT #
eros raWroad /iv dWo ve,
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DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY ttS& NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED OZ'/1-07 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. ,/93
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
�75t ff LL3galAtc
s
/�?_-tdd Ct
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring / Pit
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope % —
HORIZON I DEPTH
Texture groupE
Consistence
Structure
Mineralogy
HORIZON H 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
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: • Z J
EVALUATION BY-
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 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
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
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
LYQtgs
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)