255 Indian Hills Rd •Permittee.'s-- _ DAVIE COUNTY HEALTH DEPARTMENT "
ttr. Environmental Health Section PROPERTY INFORMATION
Name: 3w 1
P.O. Box 848 I I'
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Directions to property: �„-�`�-�'^ X f 7` f Mocksville,NC 27028 Subdivision Name: �'1 CJS Q 11
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t y -��� Phone#:336-751-8760
�ir1i- iN`1 1 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION ILL(,
AUTHORIZATION NO: 002813 A Road Name:� `` 1�.,�� .�� 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 Fo►m/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” ap r 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
1
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMEN' L HH L"I'N'SPE AL T) DATE SS ED
RESIDENTIAL SPECIFICATION:BUILDING TYPE J #BEDROOMS 3 #BATHS #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 e GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 7`+ �` LINEAR FT."
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IMPRO EMENT 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-
OPERATION PERMIT n'A� b� _i t e
SYSTEM INSTALLED BY: !u � /,r'-
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AUTHORIZATION NO.V A OPERA ON PERMIT Y: ` DATE: f
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**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE TH TE DESC I ED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISP AL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02(Revised)
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nlser►tilee'$ DAVIE COUNTY HEALTH DEPARTMENT
Name: ,, 1 Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: 1" 11'` Mocksville,NC 27028 Subdivision Name: Q r n Y1
4 �� Phone#: 336-751-8760
s rad 1 tn.}a qv,) Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# - -
SYSTEM CONSTRUCTION
002813 f'. =, � � ,.
AUTHORIZATION NO: A Road Name: '' 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 11 of G:aS:'Chap r 130A,Wastewater Systems,Section.1900 Sewage Tfeatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
! 'IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRON PENT; L HEA TH SPECIAL ST ,4 DATE I SC?ED N
RESIDENTIAL SPECIFICATION:BUILDING TYPE BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOTSIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD} --RC.�t_.)NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ►`✓_ LINEAR FT. C t'
OTHER 4
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REQUIRFITE MOODIFICATIONS/C ITIDNO ITIDNO ONS: `r' --D` •�� � ��y t / '-�^' ' ' �"
IMPRO EMENT 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.
OPERTION PERMIT n +1 1
L�'' SYSTEM INSTALLED BY: �-�—
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Ntri T'� °`1-3
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60
AUTHORIZATION NO. ` IOPERATION PERMIT DATE: I v
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA M ESC B D 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 0=(Revised) _j j o -# l q3 6 t - -I &251
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(588)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position LA
Slope %
HORIZON I DEPTH �—
Texture group
Consistence
Structure
Mineralogy
HORIZON H DEPTH •
Texture roup
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON 3
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
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 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
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
NDIPS
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 05/05 lRevicedl