257 Madison Rd (2), , _ . _ , _ �,,,�.s �
. , ; , , . . . . . . .. . � _ _ .. , �S �.�"P.. .:Z°.�o' � d -
AUTHORIZATION NO. O 5 9 6 DAVIE COUNTY HEALTH DEPARTMENT �'� s�i-96
•' " � ' Environmental Health Section PROPERTY INFORMATION � Z�,,�8�
Periiiit[ee's , �• P.O.Box 848
Name: I� • Mocksville, NC 27028 Subdivision Name:
� _ �' Phone #: 704-634-8760
Directions to property: � i�`J(C%[3�'`�n� �'(" Section: Lot:
� AUTHORIZATION FOR
1.,,,.: . WAST'�WATER �, �_�/ `'
�� l /' ���� f� � `,' �" �� SYSTEM CONSTRUCTION Tax Office PIN:# � d0_ � � _ �i �`/" .
Road Name: ��v o/F' ,�iC' . Zip: - r��� �fi
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pernuts. �
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
-�
HEALTH SPE IALIST DATE�.
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
_ � ..�. .
�.: ., ..;
�r �..,".c. �.:..:r:, ...,f :::....... ...... .. ... . .. . ,. .. . .�;F. . . ,�I/�
.. . '._ �d �y 4 . . Y . . . . .. _ . . . � � � � ' �/� � ��� ♦ G+ ' � 0 w ��/'A V � .-
DAVIE COUNTY HEALTH DEPARTMENT --�'""' �' µ8�
"` ,,; � o .�� ' ^ ` ` " - '�IMPROVEMENT AND OPERATION PERMITS PROPERTY INFOR�VIATION � ���
, Permit"tee's 'p�!� , � � �.�;� /� � . �,;
� . Name: ` ' =�" � �='��'1 ^ � t <�. � * .��r,'� Subdivision Name:
, • R �. � -
Directions to property: % �� � `� r �°': ` f i'.'��`j � � . � ' , i Section: Lot:
,�`� IlVIPROVEMENT � _
r" % ,.� r, PERMIT � Tax Office PIN:# �t'� r<�/% -/'' r� - �� �� I' �•
, - _ Road Name: �l�'i,�? v t>�i �1'�' Zip; `r,`,1 r ��.:'-"y �
**NOTE** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON 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)
l^ r� "`**NOTICE*** THIS PERNIIT IS SUBJECT TO REVOCATION IF STI'E
y�° �y r��'�' �dj���'.G�� �! -� PLANS OR TI� INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE .�� # BEDROOMS �� # BATHS �# OCCUPANTS �� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE IC TYPE WATER SUPPLY ( C� DESIGN WASTEWATER FLOW (GPD) � r� � NEW SITE �/� REPAIR SITE
i- �.
SYSTEM SPECIFICATIONS: TANK SIZE ��� GAL. PUMP TANK GAL. TRENCH WIDTH ��f ROCK DEPTH �� LINEAR FT. �. f� %'r �
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 830 - 930 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
�� �j SYSTEM INSTALLED BY:
i�
�I►.'�:�►�1
�r� � ,��
�
1'
100 �en-�° 1
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 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 WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OSN6 (Revised)
u
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'p/ / .-----�
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� ' � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� , � Davie County Health Department
Environmental Health Section ,y� r/��,
P. O. Box 848 %� d
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed !1� D �� L` Contact Person
Mailing Address �/ /� I fi- D I$ d i✓ �d h D Home Phone � 3��"Z�� 7
City/State/Zip /�1 QC��S v� �` e./U- �- �-%O �—� Business Phone �9-j Z' 3s� l
� � z39S
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ;d Site Evaluation ❑ Improvement Permit & ATC
4. System to Serve: m House ❑ Mobile Home ❑ Business ❑ Industry
5. If Residence:
!d Dishwasher
6. If Business/Other:
# Commodes _
If Foodservice:
# People .2-
# Bedrooms 3
❑ Both
❑ Other
# Bathrooms ��2-
� Garbage Disposal Q Washing Machine � Basement/Plumbing ❑ Basement/No Plumbing
7. Type of water supply:
Specify type
# Showers
# Seats
Count /Cit
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes W No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
- SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �%� X�s^�i �5��%� /' �L�� � � WRITE DIRECTIONS (from
r � Mocksville) TO PROPERTY:
Tax Office PIN: # � �'/lf (� - �. - �-a �%� 1
� l� y w� S �- �o
Property Address: Road Name �/��S'�� �� �
/� � /1'l !� 7� % So.✓ cL . �
City/Zip �'/� � �,.,-�`�G -�-.�/ � � �--
� � %�ySt o �✓ � e �f-
If in Subdivision provide information, as follows: 1
1
Name: �
1
Section• Lot #: �
1
1
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter
are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is
falsified or changed. I, also, understand lhat I�am responsible for all charges incurred from this application. 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 �� �" � �
as necessary to determine the site suitability.
DATE ��" � 9' 9 � SIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
_ . , , DAVIE COUNTY HEALTH DEPARTMENT
'��. • Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT' S NAME /� � l� DATE EVALUATED /� . S���
PROPOSED FACILITY PROPERTY SIZE �/7 f�l'�
SUBDIVISION ROAD NAME ��C, ,aD:✓'
Water Supply: On-Site Well Community,
Evaluation By: Auger Boring �/ Pit
HORIZON I DEPTH
Texture group
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
SITE CLASSIFICATION: ��
LONG-TERM ACCEPTANCE RATE: < <
REMARKS:
DCHD (01-90)
Public c�
Cut
EVALUATION BY:
OTHER(S) PRESENT:
LEGEND
Landscaae 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
Moist
VFR - Very friable
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
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
Mineraloev
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 - gaUday/ft2 �
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