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AUTtiiORZATION N0:
0747 DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section PROPERTY INFORMATION
`:Per gitte'e's P.O.Box 848
NameMocksville,NC 27028 Subdivision Name:
VIM
Phone# .704-634-8760 W a�
Directions to property:- +` Section: of
AUTHORIZATION FOR
WASTEWATER . Tak Office PIN:#
SYSTEM CONSTRUCTION -
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 G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
t ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION .
/•.(i �(Y` cl��fp�—�.` IS VALID FOR A PERIOD OF.FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
-
-
DAVIE COUNTY HEALTH DEPARTMENT
,M IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
'Peri
tee,'g=
Name: ±Z .E1E '�I Subdivision Name:
Directions torproperty:�' ,f ",r-/ Section: Lot: Az
IMPROVEMENT x YNO 7 Q Q
PERMIT Tax Office PIN:#
Road Name: Zip: 14 .
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
X`t l,c t'�l 1_41, ;1 " •�,� 4'" PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THUS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE & #BEDROOMS F#BATHS-,;2—#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE�I�TYPE WATER SUPPLY ( 6 DESIGN WASTEWATER FLOW(GPD) NEW SITE L- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /man GAL. PUMP TANK GAL. TRENCH WIDTH,? ROCK DEPTH 1, LINEAR FT.?O d
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)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
iAtasc
AUTHORIZATION NO. Q OPERATION PERMrr / DATE: /
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYS CRIBED 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 EVALUATIONAMPROVEMENT PERMIT&ATC
Davie County Health Department
Environmental Health Section D
P.O. Box 848
MAR 2 6
Mocksville,NC 27028 197
(704) 634-8760
,
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
r
1. Name to be Billed /tQ� 4th T- 161&
Contact Person -e C7 /l.-t
Mailing Address I9Q !S V�k NZ Jh 6- Home Phone `�// e�
City/State/Zip /I'�6 C//( lk A1,. ItoY)d OrP' Business Phone q7'Q 7 / !�l
1 2. Name on Permit/ATC if Different than Above
4 Mailing Address City/State/Zip
3. Application For: Site Evaluation [Wrnprovement Permit&ATC [ ]Both
4. System to Serve: [gfiouse [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People #Bedrooms _ #Bathrooms—J— Wishwasher[ ]Garbage Disposal
VWashing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other:Specify type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. 'Type of water supply: [✓County/City [ Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [kl"No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***AXENVOF THE PROPERTY MUST BE
SUBMITTED WITH T APPLICATION.
Property Dimensions: l0 X c�lJ� ;WRITE DIRECTIONS(from ksville)TO PROPERTY:
Tax Office PIN: # - - t �4 / 1 2!� 11'eV WZ
Property Address: Road Name a71-h�'►'— CI - �► O f o A lk
i
city/zip 4 o -e M -t
' If in Subdivision provide information,as follows: / eb V174
Name: �T�oYs 6h�t C er5
Section: Lot#: 6 ;
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 that 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 l'( Q- I eA) t conduct all testing ocu s as necessary to determine the site suitability.
DATE '3�— �G�` SI ATURE
Revised DCHD(06-96)
THIS AREA MAY BE USED FOR DRAWINC� YOUR SITE PLAN:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME .9r ZJ DATE EVALUATED
ADDRESS PROPERTY SIZE �7�flG
PROPOSED FACIILTY LOCATION OF SITE SUi9/�/},JPI
Water Supply: On-Site Well Community Public L____1
Evaluation By: Auger Boring Pit 1,� Cut
FACTORS I 2 3 4
Landscape position L
Slope -41
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
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=/;y/
SITE CLASSIFICATION: �l EVALUATED BY:
LONG-tERM ACCEPTANCE RATE: V= 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
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very fine 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 watef 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