2303 Milling RdPermittees" DAVIE COUNTY HEALTH DEPARTMENT �/31Oq
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Name: ' Environmental Health Section PROPERTY INFORMATI
i .r P.O. Box 848
Directions to property: Mocksville NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER i
p� t�� � � SYSTEM CONSTRUCTION
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Tax� ffice PIN:#
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AUTHORIZATION NO: 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
(,_ _ c ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
c-� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 7
RESIDENTIAL SPECIFICATION: BUILDING TYPE #OUA# BEDROOMS # BATHS # OCCUPANTS v GARBAGE DISPOSAL: Yes or Nc
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE -0 TYPE WATER SUPPLY ` y DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK r 1 r A- GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. L
OTHERII 11 �i tl li t" (IN It � �t 1-,f 1,6 el 1 -1 e
Lfe� CIiS1+' 61,d
REQUIRED SITE MODIFICATIONS/CONDITIONS: S ' �"
IMPROVEMENT PERMIT LAYOUT
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1100, hi VP
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL EEN 8:30 - 9:30 A.M. ON Y OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT �O C A
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SYSTE ALLE G/ !rr f lv
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AUTHORIZATION NO.e�/ ` 9 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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02102 (Revised)
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Pettees -� ��� "' Q DAVIE COUNTY HEALTH DEPARTMENT
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Name:+ �" ` �` ,-� r Environmental Health Section PROPERTY INFORMATI `/
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P.O. Box 848
Directions to property:
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Mocksville, NC 27028
Subdivision Name:
Phone #: 336-751-8760"
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Section: Lot:
AUTHORIZATION FOR
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WASTEWATER
Tax Office PIN:# -
SYSTEM CONSTRUCTION
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AUTHORIZATION NO:29
Road Name: ZI
**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 I 1 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
RESIDENTIAL SPECIFICATION: BUILDING TYPE 116t156# BEDROOMS "f # BATHS # OCCUPANTS �, GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZEy 0 TYPE WATER SUPPLY ` V DESIGN WASTEWATER FLOW (GPD) J r� NEW SITE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK _/ l 1 GAL. TRENCH WIDTHS ROCK DEPTH f 3- LINEAR FT.
OTHER i 11 f4ID • lL1l�� �� ,a.! l /�.rr. c, ) �,1• �, r ! r �l.r.r i
r I t� 1: • �J((t f !t < o
REQUIRED SITE MODIFICATIONS/CONDITIONS: 5' t 1 5!. r r
IMPROVEMENT PERMIT LAYOUT (-1
i t'1-rL tt r; fit✓ f t'1' G r /�.� / r L'
(' C let r V� Crf r
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL B WEEN 8:30 - 9:30 A.M. ON )P Y OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM LLE B,Y:
-} 0
-�` 41 I ,
AUTHORIZATION NO. ! / 8 OPERATION PERMIT BY:�cr� ''� .- r 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 NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME � ��r f" 81l&-ND't bq wkC-le h' PHONE NUMBER W9-
ADDRESS l%Sdi& & Z 79
S DIVISION NAME
LOT #
DIRECTIONS TO
M-MLISF...e
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY #us -e NUMBER BEDROOMS 7' NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING h %M%yIde,
kes Nd � worbna . Domad a/i3lo
DATE REQUESTEINFORMATION TAKEN BY Q
This is to certify that the information provided is correct to the best of my knowledge, an"at lynderstand I am
for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. ,r93't `lr "o/' dtk-art bK.�lvr� s 7 s7-c�''� loc4�/� 6P �r iJ•? if
APS - Davie County NC Public Access
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
bf.-.e_V4a gory -e t _t. CCe�cr_ a 3a3 Ec<<�5
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring_, Pit
,A Aa c <<S U G Ge, /i C
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
0— if $
Texture groupG
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
LONG-TERM ACCEPTANCE RATE
E,2.'26
SITE CLASSIFICATION: /' 5 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: G• 7 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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
Moist
VFR - Very friable FR - Friable FI - Firm VM -Very firm EFI - Extremely firm
3y -d
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
Nfites
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprohte - 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 05/05 (Revised)