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881 Liberty Church Rd (3)WMI.tDAVIE COUNTY HEALTH DEPARTMENTName:Environmental Health Section PROPERTY INF RMATION P O B 848 t0 IL -'u, I 0,J --I V . . ri1 ox I Directions to property: Mocksville NC 27028 Subdivision Name: t.✓, \�t� ; f)>J�1. �'n`�T Phone#:336-751-8760 Section: AUTHORIZATION NO. AUTHORIZATION FOR WASTEWA FR Lot: SYSTEM CONSTRUCTION Tax Office PIN :# - i 002708 A Road Name. }C, � t� t: 1 tiZ � I" p: C **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 compliancewtdi�Ai-tic a 11 of G S'C-h Ater 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) / r.... 1 1r f 0 -�' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ��IS VALID FOR A PERIOD OF FIVE YEARS. sNVIRONMENEAL�TI 6PE'CIAL�ST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE t Ny # BEDROOMS � # BATHS Z # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE ���, ) # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE L4! 'TYPE WATER SUPPLY L"�I Iv DESIGN WASTEWATER FLOW (GPD, D NEW SITE REPAIR SITE 2 r SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH st ROCK DEPTH ` LINEAR FT. 2� ` OTHER{E L�a,�.irtaJSt►`:w..�, iSirrlt.rTtoJ REQUIRED SITE MODIFICATIONS/CONDITIONS: t'`' U� CID I.iTOJ� I ke L.' a�:S IMPROVEMENT PERMIT LAYOUT Z. 3 C - ,l 1 FI vt. 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 ��A SYSTEM INSTALLED BY: ;5 **Mm 1 3Z _ RV11 TO, LUA U — I r AUTHORIZATION NO. OPERATION PERMIT B DATE: � 0)ZO �p **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY ESCRIBED ABOV S 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. tXMD OM (Revised) Poo -4 9WO020 �, �:fiNvolee-A 5702 ' Pernuttee' l`�` • DAVIE COUNTY HEALTH DEPARTMENT `-"Name: �` " �`',.�►t: Environmental Health Section PROPERTY INF RMATION 1 P.O. Box 848 Directions to roe j"°Y 1 ` 1�4ocksville, NC 27028 Subdivision Name: i property: rty_ -r Phone #: 336-751-8760 IJ Section:_ AUTHORIZATION FOR Lot: Tax Office PIN :# SYSTEM CONSTRUCTION - "A[J qOIIdiXT (3lq1�T0: 002708 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 Gter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) a' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ...- �'�':��.'--<•`"''.�`•�. IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENT L-4EALTH SPE6ALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE 1V) 0S_,# BEDROOMS � _# BATHS Z # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPPES �# PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: /Yes s�or No, LOT SIZE TYPE WATER SUPPLY 1YDESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �' LINEAR FT. OTHER1 REQUIRED SITE MODIFICATIONS/CONDITIONS:,1 �"`") �"'' Q'Cl >vl41 IMPROVEMENT PERMIT LAYOUT a 4V r I- r �l• ,` lIJ3 rtivr: upj C 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: G3 G M k1V N Q�l'%Ky STD AUTHORIZATION NO. OPERATION PERMIT B DATE: D **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY SCRIBED ABOV S 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. DCHD02/02(Revised),`�• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION WAMA APPLFOR IMPROVEMENT PERMIT (REPAIR) NAME PHONE NUMBER ADDRESS DbLI T l V� Ll r PAD SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED Z> NAME SYSTEM INSTALLED UNDER _--AAA-Z7 TYPE FACILITY tit NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING W c� 10 QDA *r DATE REQUESTED 1� I« IDS 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 •lfbpow- APPLICANT INFORMATION Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation On -Site Well Community Auger Boring Pit PROPERTY INFORMATION Public .� Cut • ®©®0®�� Landscape position group Consistence HORIZON 11 DEPTH groupTexture Texture ConsistenceM-R•M�a®��®���� Mineralogy HORIZON III DEPTH Texture group Consistence Flows HORIZONMMNTNMMMI DEPTH ���■®��s®® Texture group ConsistenceSOIL Mineralogy WETNESS • • • We hl, SAPROLITECLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: EVALUATION BY.. - OTHERS) PRESENT: nCiviHxn�: 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 ONSIST .N . . 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 LYQtrS 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) ■■■■■■■■■■■eee■■■■■■ee■■e■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■s■■■■■■■ ■■eee■■■■■■■■e■■■■■■■■■■■■■■■e■■■■■■e■e■■ae■■■■■■■■■■■e■■■■■■e■■■■ ■■■■■■■■■e■■■■■■■■■■■■■■■■■ire■■■■■■■n■■■■■■■■■■■■■■■■■e■■■■■■■■■ ■ee■■■■■■e■ee■■■■e■e■■■ee■■iiCC:�wiiriC�A11■■■■■■■■■■■ee■■■■■■■■■■■■■■ MENNENMENNEMMOMEMEN MENNEN MENNENMEMNONEMEMEM ■e■■■■■eee■■■■■■■■■■■■■■■■■■■■n�•■■■■■■■e■■■■■■e■e■■e■e■■e■e■e■■ee■ ■■■■■■■eee■■■■■■■e■e■■■■■■■■■e■■aa■■e■■■■■■■■■■■■■■■■■■■■■■■e■■■■■ ■■■■■■■e■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■e■■■■■e■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■e■■■e■■e■■■■■■■■■■ee■e■■ ■eee■■■eee■■■■■■■e■■■■■■■■■e■■■e■■■■■■■e■■■■e■■ee■eee■■■■■■ee■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■eeeeeeee■■■e■ee■e■■■■ecce■■■■■■■■e■eeee■ee■■■ee■■■■■■■■■ee■■■e■ ■■■■eeeee■e■■■■■ecce■■■■■■■■■■■■■■■■■■e■■■ee■e■■■■eee■eeeeae■eeee■ ■e■■■■■e■■■■■ee■■■■■e■■ecce■■■■■■■■■e■■■ee■■■e■■■■■■■e■■■e■■e■■■■■ ■■■■■ecce■eee■■e■■■■eeeeee■■■■■■■■■■■■■■.■■■e■■■■e■■■e■■■■■■e■■■■■ ■■■■■■■ecce■■e■e■■■■■■■■■ee■■■■■e■eee■■eee■■■■■■eeeee■eeee■e■■ee■■ ■■e■ee■■■■e■■■■eee■■■■■■■■■e■■■■I�ee■■ee■ee■■e■e■e■■■■e■■eeeee■ee■ ■■eee■■■■■ee■■■■■e■■■e■■e■e■■■e■ ■ee■■ee■■■■■eee■■eee■■■ee■e■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■