156 Camden Court Lot 6 .rrFs .6 .t' `_L G.,+f4_ar t£•»a;.n EzA'' %xti t --' w det'y-r - '7 _ , r' ,a.':;14..c,
AUTHORI7.saATION No:'0 6 9 2 DAVIE COUNTY HEALTH DEPARTMENT
r Environmental Health Section PROPERTY INFORMATION
Permittee's 1 P.O.Box 848
Name.` Q /�� Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property: 4 .J,J �f)a f'E'..�+C.l Section: Lot: .9
AUTHORIZATION FOR /
WASTEWATER Tax Office PIN:#��(Ad � ��u
SYSTEM CONSTRUCTION
Road Name:. f1roO&- p aS'jQII
**NOTE**This Authorization for WastOwater 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 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.
ENVIRONMENTAL HEALTH SPECIALIST > DATE ISSUED
.. n i'�lf-`ti ti,,• -..»iw ,.kis ': ti.r..� ,H,."- _-.,,,,d 11µ #'w.,:��r:.��r.,,,.J`. _
� ��,��;'qP '+' r , + , 1 DAVIE COUNTY HEALTH DEPARTMENT
4
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Perrlut(ee's' `
Name:` .f?G'� v Subdivision Name:
Directions to property: ` 11vf'' Section: Lot: .n
EAPROVEMENT
PERMIT Tax Office PIN:#k r �
1? '
Road Name:4121 PV ? ip. F '�'6 /
**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)
.i;f ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
" .,:..� r PLANS OR THE 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/j #PEOPLE #PEOPLE/SHIF]r #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE -- TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS:TANK.SIZFf d9&) GAL. PUMP TANK GAL. TRENCH WIDTH'_ ' ROCK DEPTH 1 LINEAR FT. ,9D
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*"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)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: �� rCL
O�o
poX
}OL)
°j
AUTHORIZATION NO. Z OPERATION PERMIT BY: 1DATE:
**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.
DCHD 05/96(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEM
Davie County Health Department f.1 Vj `:J '
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 J 4
:: .1. Application/Permit Requested By
Mailing Address 1.25 �` �' t3 Home Phone 9�B' Z0 2_
Business Phone
..2.'Name on Permit if Different tlian Above
3. Application for: General Evaluation �'cSeptic Tank Installation Permit
4. System to Serve: LYHouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry her ❑ Unknown j
5. If house, mobile home: Subdivision �Q �� S Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No.of Bedrooms - a Washing Machine
No. of Bathrooms .2 2-101ishwasher
Dwelling Dimensions ❑ Garbage Disposal i
6. If business, industry, place of public assembly, other: Specify type 1'
• i.
No.of People Served No. of Sinks i.
No.of Commodes No. of Urinals
No.of Lavatories No. of Water Coolers
No.of Showers Water Usage Figures
" r.
7 Type of water supply: tKPubli ❑ Private ❑ Community.
y�� ��d .
8..Property Dimensions Sewage Disposal Contractor �•
9: Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes KNo
If yes, what type?
'NOTE: Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989. J;
t:
l:
Directions to Property: PROPERTY INFORMATION REQUIRED:
�7 iY
Tax Office PIN #
I
<mDke- Road Name Box # (if available)
j
I,
i
J This is to certify that the information provided is correcttote o le e a d I understand I am responsible for all charges
incurred from this application.
�- yrs �.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION IQ BE DONE ON ABOVE DESCRIBED PROPERTY '
MUST CHECK ONE: ❑ 1. I OWN the property. P--2. I DO NOT OWN the property.
1f you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: b
I hereby give consent to the authorized representative of th avie Cou ty Health epartment to enter upon above described i
property located in Davie County and owned by
f to conduct all testing procedures as necessary to determin said si ui bili for a ground absor • n sewage treatment
and disposal system.. /
DATE SIGNATURE
D6HD'(1/M l
J �,
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED �lGL7.6
PROPERTY SIZE `���0
ADDRESS
PROPOSED FACIILTY •���/�s 1° LOCATION OF SITE
A �
Water Supply: On-Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position .L
Slope
HORIZON I DEPTH
Texture group .�
' Consistence `
Structure
Mineralogy
HORIZON II DEPTH y
Texture groupG
Consistence
Structure Abiiit
Mineralogy
HORIZON III DEPTH
Texture group
Consistence o
Structure
'Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION ,$
LONG-TERM ACCEPTANCE RATE 3
SITE CLASSIFICATION: _ � in i&11 EVALUATED BY: All
LONG-TERM ACC TANCE TE: 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 ;lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Vf.-.-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
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(01-901
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