123 Peaceful Valley RdPenite�f��QAV:
C_DAVIE COUNTY HEALTH DEPARTMENT
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Pnuronmental health Section PROPERTY WEORMATION \ jY
P.0. Box 948
Dueedons to property:/TJ�/'I �1. ��. ✓ /" ��•� Mock,,ille.NC27028 Suhdmsion Name: l\
Phonc 4:336-751-8760 Section:_.Lot:
AUTHORIZATION FOR -
TYASThWA"TF.R Tax 011icrBlN:N
_ -
SYSTEM CONSTRUCI ION - c I / -
AUTHORIZATION NO: 002626 A Road Name,
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**NOTE"This Amhonnnion fol Wasoxaer Svstem Cowmetion MUSDBL ISSUGD Fy the Davie Count, n,milmentaLHealth Section prior
to rcwalim oLunr BuilJinp Pemuh. Thi. fiimUAtnhon/ation Nan&l r§huuld h• preientcd to the Davie County Building Inspersions
Section .1900 Sewugc TmatnSnl and D1,rx"al Syxtetml
•' NOT'ICB+x*
SPECIALIST DATE ISSUED
FIVE
RESIDENTIAL SPECIFICATION: BUILDING TYPE a BEDROOMS NL# BATHS #OCCUPANTS GARBAGE DISPOSAL>Yeser No
COMMERCIAL'SPECIFICATION: FACILITY TYPE - #PEOPLE_ #PEOPLFISHIFT_ #SEATS INDUSTRIAL WASTE: Yes or No
LOTSIZE TYPEWATERSUPPLY f//DESIGN WASTEWATER FLOW IGPDI 1576 NEWSITE REPAIRSITE V_/
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMPTANK \ /GqC TRENCH 0.'IDTH 2V ROCK DEPI'H�LINEAR FTS
ISd
REQUIRED SITE
LAYOUT
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BE VEN 8:3D-900 A.M. ON THE DAY OF INSTALLATION. TELEPHONE #IS (336) t5687E0...
SYSTEM
E=1
Sr.1C9 I
eoj
AUTHORIZATION NO.aQk- OPERATION PERMIT BY: ` P' -r -
INDICATE
Dean O]AztPevluEl'
INSTALLED IN COMPLIANCE
\LL IN NO WAY BE TAKEN AS A
Permnrce sJ jr^�Y// DAV&ZOUNTY HEALTH DEPARTMENT
�1/"^''���/��/%5 7 '' I .F nvirunmental�HealIh Section PROPERTY'INPORMATION\
11.0. Box 848
D coons to Propcny: /.f a J ,\1ocA, ille, NC 27028 Subdivision Name
Phone 4:336-751-8760 Section: Loi:''
,\UT'HOR17ATiON FOR
\\ CONS'TRIX Te.c OI'1'icc` PIN:#_-
SI:S'fFV C(1N'STRECTI(IN . _
002626 A
"NOTE Thi, AuthonPtion far,VaMtw ter S\ 1111C nslmuun�'MUS BE ISSUED bs the Davie County £mlrnnn3ened Hcullh Section prior
In Is u.mce of any Building Permirs. This FomUAulh' m pion Numh, should he pn..crued to the f1rvie County Buildinginspectians
/Office when Ipplun), for Building Pernin,
(In corrphance w'nh Anicle I I, of G.S. Ch Iprn 130A. Wa.Iewa et S"'Ienu. Section.1900 Sewage'Ireatmenl and Disposal Systems)
""*NOTICE—'P HIS All MORIZA'I'[ON FOR WASTE
IS VALID FOR PERIOD OF FIVE
HEALTH SPECIALIST DA'Z'E ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS BATHS 7 #.00CUPANTS ] GARBAGE DISPOSAL: Ycsor No
-c,
COMMERCIAL SPECIFICATION: FACILITY TYPE pPEOPLE pPEOPLPlSH11T #SEATS_ INDUSTRIAL wAST@Y<s or No
LOTSIZE TYPE WATER SUPPLY ��/�/DESIGN WASTEWATER FLOW (GPD)y� NEW 51TE REPAIR SITE ✓tel
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP "TANK ��14. TRENCH WIDTH �V ROCKDEPTH%:I LINEAR FT.A
REQUIRED SITE MODIFICATIONSICONDITIC
IMPROVEMENT PERMIT LAYOUT
s `
L -ties F 5";,. �.- y„ � ;,, ,Il(•�T '-
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BEf W EEN BOB- 9 30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE a IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED
xN ��
AUTHORIZATION NO� OPERATION PERMIT BY: ( / DATE:,
^THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WfM"nCLEII'OFG.S:CHAPIER130A.SECTION-.IM SEWAGE TREATMENT AND DISPOSAL SYSTEMS BITSHALL IN NOWAY BETAKENASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANS GIVEN PERIOD OFTIME.
ociiouzox lP.awl )/�e/�
911 ZVA/4
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
• P I A ION FOR IMPROVEMENT PERMIT (REPAIR)
NAME r l`� ,PHONE NUMBER r
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED � NAME SYSTEM INSTALLED UNDER G��%�%•'Z°
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY�e--SPECIFY PROBLEM OCCURRING
DATE REQUESTEDJZ/3/Oh INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my
SIGNATURE OF OWNER OR AUTHORIZED AG
Rev. 1193
that t understand I ar3r responsible for all ctirgeq incurred from this application.
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #:
Billed To:,
Reference Name:
Proposed Facility:
PROPERTY INFORMATION
Tax PIN/EH #:
Subdivision Info:
Location/Address:`
Property Size: Date Evaluated:
Water Supply: On -Site Well Y Community Public
Evaluation By: Auger Boring V/ Pit Cut
FACTORS
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
1f
Structure
d
Mineralogy
HORIZON 1I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
W1.
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: 2W
OTHER(S) PRESENT:
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
CONSISTENCE
Moist
VFR - Very 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
'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
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