187 Ken Hoots LnPetmittee'0' : �'? DAVIE COUNTY HEALTH' DEPARTMENT
r / '( c' f ' gid` , .-� t Y Environmental Health Section PROPERTY INFORMAAI 09
Name: / V �i,.• � LLQ I
P.O. Box 848
Directions to property: -rO. 0 AA 1 U Mocksville, NC 27028 Subdivision Name:
( 1 Phone 36-751-8760 a'-'°
P 'rr ►�(f 110 �i'td C �e}P, �, �{ Section: Lot:
SYST
jj i fj AUTHORIZATION FOR
�-� (1 i1�1 tl. -10 r* WASTEWATER Tax Office PIN:#��
EM CONSTRUCTION „
AUTHORIZATION NO: 002866 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
i_IS VALID FOR A PERIOD OF FIVE YEARS.
HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS P�— # BATHS J_# OCCUPANTS a GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE 1(OPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGIIN WASTEWATER FLOW (GPD) ` NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK S SIZE NVOGAL. PUMP TANK —AI&AL. TRENCH WIDTH f ROCK DEPTH- LINEAR FT. �e
OTHER Y�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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75 '
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IIFOR 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 P RMITr tt Yw /
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AUTHORIZATION NO. OPERATION PERMIT BY: DTE:
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**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALL D IN" WLI INCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL INN WAY BE TAKEN AS
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHDovo2(Revised) nae-/-
Pei4nitEee s � ;• . t `' DAVIE COUNTY HEALTH DEPARTMENT
.Name: t r' '(' Environmental Health Section PROPERTY INFORMATI� .. � cry�qlog.,
- G P.O. Box 848 I
Directions to property: r. �A Mocksville, NC 27028 Subdivision .Name:
tc,R <t, ,)$Phoned#336-751-8760
�' i �. Section: Lot:
0j� ff j AUTHORIZATION FOR +�
(1 .. t Ur 1 Ci-•r�"c� WASTEWATER
Tax
SYSTEM CONSTRUCTION TyOffice PINt:# - }
'AUTHORIZATION NO: 002066 A Road Name: Zip. y�
**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.
ENVI ONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS" # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPYCIFICATIO� FACILITY TYPE # P 9PLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ) r TYPE WATER SUPPLY [:� DESIGN WASTEWATER FLOW (GPD) V NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE % I GAL. PUMP TANK /X' L. TRENCH WIDTH U ROCK DEPTH V&LINEAR FT. �
OTHER
iP 'y !7� t�.N �% "�' �! �'(�G1 C�( �1 rd ,ruSllr
REQUIRED SITE MODIFICATIONS/CONDITIONS: _ t;l G �( U
IMPROVEMENT PERMIT LAYOUT
�r ovvA
�, to 1, 51
,o��
x 75
d •
s 4 f { y+ e—
�M
/ J
r
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 P MIT SYSTEM INSTALLED BY: G�AV ff�eYetl/, ld
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AUTHORIZATION NO. OPERATION PERMIT BY: DA :
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INST LED IN C&IPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -
DCHD 02102 (Revised)�%�-/
+ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
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Water Supply: On -Site Well / Community
Evaluation By: Auger Boring / Pit
PROPERTY INFORMATION
467 Ae I AV`61,4
�Z 7C70 G
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
15G
Consistence
Structure
Mineralogy+C
X
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
40
LONG-TERM ACCEPTANCE RATE
7
SITE CLASSIFICATION: iJ
LONG-TERM ACCEPTANCE RATE: 0' ' ' -7�
REMARKS:
LEGEND
EVALUATIONBY:.� /ycZl%r�n-`5
OTHER(S) PRESENT: c Aa ` 'P
I, ndseaue 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
}iet
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
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)
LIAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/05 (Revised)