173 Bowman Rd Davie County Health Department
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ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028Qo
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.***
RMEAroc�eS �� � ,�{�-.� DATE "T - �I - I� AUTHORIZATa�NIIMER
N
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE.LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
T �l
**OWICE*H THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIROMIENTAL HEALTH SPECIALIST DATE
DCHD 10/95
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DAVIE COUNTY HEALTH DEPARTMENT f�
IMPROVEMENT PERMIT and OPERATION PERMIT a��
IMPROVEMENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
PROPERTY ADDRESS _ 44 kJ n'1R7 t TCL .- a 7�a DATE 11 -71&
LOCATION Lo N - \ CS`c� �`� � ate.
SUBDIVISION NAME LOT NUMBER SEC./BLOC( NUMBER
RESIDENTAL SPECIFIC.RTION: BUILDING,TYPE�, t rte # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye /No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATSr INDUSTRIAL WASTE: Yes/No
LOT SIZE � TYPE WATER SUPPLY DESIGN WASTEWATER FLOW ('GPD) O NEW SITE '-**/ REPAIR SITE,
SYSTEM SPECIFICATIONS. TANK SIIE GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH 1�0' LINEAR FT.
x .
OTHER ?' z,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT'TO REVOCATION IF SITE FANS OR THE INTENDED USE CHANGE. YO.IR WASTERWATER SYSTE,R.CONTRACTOR MijST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
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0
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JPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF`INSTALLATIONI TELEPHONE # IS 1704) 634-8760.
OPERATION PERMIT , SYSTEM,INSTALLED BY
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AUTHORIZATION NO. y 4 OPE BY DATE ' 9
**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. I
DCHD 10/95
I DAVIE COUNTY HEALTH DEPARTMENT i" jS 1�'� qj,
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
PROPERTY ADDRESS _t.JD 1c1 Wla-1 1\C�.. — A 7"A DATE 4- -Ile
LOCATION f �� (S"r. �''c�� r.* . �cs- y )I-�a`�;
SUBDIVISION NAME LOT NUMBER SEC./BLOC( NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE V!. r,';c.e # BEDROOMS _ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye /No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL. WASTE: Yes/No
LOT SIZE :. b TYPE WATER SUPPLY t DESIGN WASTEWATER FLOW (GPD) rO NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH 11� LINEAR FT, 00
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT: IS SUBJECT TO REVOCATION IF SITE PIANS OR THE INTENDED,USE CHANGE. YOUR WASTERWATER SYSTEM,CONTRACTOR MUST-,
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. R
3 �
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IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL'INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. , TELEPHONE #'IS (704) 634-8768.
OPERATION PERMIT SYSTEM INSTALLED BY
J3&1
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AUTHORIZATION N0. .V ' TIM PERMIT BUG �l4� _ DATE - L
**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"SEWAM TREATMENT ANDDISPOSALSYSTEMS", BUT-SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE-SYSTEM WILL4UNCTION SATISFACTORILY.FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95 x fi
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low
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department [NIOV 13
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By b q P
Mailing Address �'� /y, C• 1-J w .r �U/ N Home Phone 1'
Business Phone
2. Name on Permit if Different than Above A �-I-t=S J Lo S D iJ 4.-J -_
3. Application for: General Evaluation d Septic Tank Installation Permit
4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry / El Other El Unknown
5. If house, mobile home: Subdivision f r �r�-4 14-e, Section Lot #
Z
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
i
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions 34 X 2-- ❑ Garbage Disposal `
r.'
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
k;
No. of Showers Water Usage Figures :
7. Type of water supply: ❑ Public j/Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor .
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 4--No
If yes, what type?
t I
"NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
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PROPERTY INFORMATION REQUIRED:
Directions to Property: Tax Office PIN /
/ f� 4 t4 Road Name sbwi1^44 ^07
5`
Box # (if available) ;.
T n r t
Q p �.d v �. ?v K , 7 kr city _ �6C�sy,'ll�e. /J� e , is
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This is to certify that the information provided is correct to the b f my knowledge, and I understand I am responsible for all charges
incurred from this application. t
DATE S4NATURE
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CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. '2I DO NOT OWN the property. '
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine s site's suitability for a ground absorption sewage treatment
and disposal system. _
f DATE SIGNA E
DCHD(1193) p
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IQ3-49 P•N
353 . . V P;,4
(2 . 09A) 243 27, V
19 P413
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', M"OR
4499 U, ^ pR� �d� U
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"' 9406 e3
259 1D r- y 1435
( 1 . 59A) Sos,B�
01 +
5301 1:14,1 A
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. 3201 1NLXLD 0 J01 :3 `�'�''s°"=-� P
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' DAVIE COUNTY HEALTH DEPARTMENT
✓' Environmental Health Section
Soil/Site Evaluation
NAME 17 a e R �'e o1��V DATE EVALUATED
ADDRESS S A P PROPERTY SIZE oL c R e
PROPOSED FACIILTY U K N o w LOCATION OF SITE V
Water Supply: On-Site Well �/ _ Community Public
Evaluation By:C FL Auger Boring ✓ Pit Cut
FACTORS 1 1 2 3 4
Landscape position < s
Sloe R 5r- 5�
HORIZON I DEPTH a II
Texture group S C I•, SC L C t- Is Ct_.
Consistence 1 -Z
Structure C R C K
Mineralogy
HORIZON II DEPTH
Texture group C
Consistence 1= r FI T!--T
Structure A P K I Kai r AvK ARK
Mineralogy AI � ► 1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S S s s
RESTRICTIVE HORIZON -- --
SAPROLITE
CLASSIFICATION S• S
LONG-TERM ACCEPTANCE RATE 33 13
SITE CLASSIFICATION: 3 S. EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: �c a
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 :lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-V,3.-y 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
3C--Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralocty
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(01-901
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• Davie Caz(tV Nealtl Department
and Xame Xealtl ffflet'
210 HOSPITAL STREET I P.O.BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
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November 21. 1995
Boaer Real Estate
142 N.C. Highway 801N
Advance, N.C. 27006
Att: Gilbert Boger
Re: Site Evaluation
2 Acre Site/Bowman Rd.
Dear Mr. Boger:
As requested, a representative from this office visited the aforementioned
site on November 20, 1995. Based upon the information provided on the
application for a site evaluation and after an evaluation was completed, the
site was found to be provisionally suitable for the installation of an on-site,
sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Charles E. Little, R.S.
Environmental Health Section
Enclosure(s)
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