194 Keith LnPermitteeAltb
D VIE COUNTY HEALTH DEPARTMENT
t ' Name:I �'�' �� �� �� Environmental Health Section PROPERTY INFORMATION
1L P.O. Box 848
(
Directions to property: r! u /� Mocksville, NC 27028 Subdivision Name:
r `� Lt1 '` IC't.C Phone #: 336-751-8760
e f Section: i.ot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
-
AUTHORIZATION NO. 003022 A Rod Name L 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 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�%i'%
ENVIRONMENTAL HEALTH SPECIALIST
,/ — �/ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 5 r # BEDROOMS ?) # BATHS ( # OCCUPANTS '�- GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE '� TYPE WATER SUPPLY (X C� DESIGN WASTEWATER FLOW (GPD) 31k6)
NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE r� AL. PUMP TANK GAL. TRENCH WIDTH — ,L 4 ROCK DEPTH LINEAR FT.�
OTHER C3I ��CtJ rc tr tY l�
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: % I N N I P I/ V V M V 7
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2.
AUTHORIZATION NO. OPERATION PERMIT BY. DATE. /
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 02/02 (nevi-d}�.�/! s V 7 !/ %7Y . 72&1
P rmittee s 4 -� C► I 1 (� �DAVIE COUNTY HEALTH DEPARTMENT
'.� 1 /� Environmental Health Section PROPERTY INFORMATION
,�.:�'e
P.O. Box 848
Directions to property: �' �'' ( `"� ' Mocksville, NC 27028 Subdivision Name:
(_ j. ? �`` fst� Phone #: 336-751-8760 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZ.ATION NO: 003022 A Road Name F-' . i k L_ ( 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 FonnJAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen -nits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEALTH SPECIALIST
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION -
IS VALID FOR A PERIOD OF FIVE YEARS.
DATE ISSUED
RESID'hNTIAL SPECIFICATION: BUILDING TYPE i
# BEDROOMS _a�_ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No 1
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE I• TYPE WATER SUPPLY �1L C ( DESIGN WASTEWATER FLOW (GPD) 3 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE" GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER 0..!r ;I !/
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
)C)6 164
P4' u f�•�
r- X,S
L
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: _
C:
AUTHORIZATION NO. OPERATION PERMIT BY: / �-�' ! `-'" ATE:
"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.
DCHn ovoz (Revised { ,
I.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Abble- 57a'MAy
l �
V,_ Ale,, 71-1 41,1
AelUC�� 14/G/-V41)/'Z�7
Water Supply:
Evaluation By:
On -Site Well _ Community
Auger Boring Pit
PROPERTY INFORMATION
F7;gg y ? " ESQ p
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position '
4—
Slope
Slo %
HORIZON I DEPTH
If
Texture group
G
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 jETEEEtQj.a7�—.
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: a Z} 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
MQISt
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EF1- 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 VO -
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME
A\6 � I -Q
�)V-�-e k
PHONE NUMBER ��—
ADDRESS
��
PLA Ca(I ---
SUBDIVISION NAME
DIRECTIONS TO
LOT #
Ce'l
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING uz� c ►.
DATE REQUESTED G( "1 ��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