495 Pine Ridge RdBermittpe'a (, [ DAVIE COUNTY HEALTH DEPARTMENT
Name: t 4 (_ ��'t��7 Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
ti Phone #: 336-751-8760
Section: Lot:
AUTHORI7,ATION FOR
WASTEWATER r, i��( - lC
SYSTEM CONSTRUCTION Tax Office PIN:# fi r g -
AUTHORIZATION NO: 002900 A Road Name: Zip::. i
**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 bavie 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
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS �_ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT 7 u # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLYc- i'I DESIGN WASTEWATER FLOW (GPD) "LyD NEW SITE RFPAiR SiTF
f � I
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH `' �r, ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
LLtJ C,�C�v1)��C ,
IA
i
11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT �—
3
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INSTALLED BY:
lift L?4 3S
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AUTHORIZATION NO. Z �� OPERATION PERMIT BY: V"-' W DATE:/ 2 -
"THE
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
/.7iD 02102 (Revised) 1 C C: li�r��!/ �FdV �' `� 7R
1 Pc[mtt DAVIE COUNTY HEALTH DEPARTMENT
c's:
Namer-r (w Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
_Directions to property: Mocksville, NC 27028 Subdivision Name:
6
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER /"
SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 002900 A Road Name: Zip: I
**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)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ZRESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY - DESIGN WASTEWATER FLOW (GPD) U NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK !`1 GAL. TRENCH WIDTH �`r ROCK DEPTH i `' LINEAR FT. t
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
I
JL
1
11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. II
OPERATION PERMIT
6� ;�i 3
My E
INSTALLED BY:fit
a
/* Xy 166
`W
AUTHORIZATION NO. OPERATION PERMIT BY: I IP"4) DATE: /2 0
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 02102 (Revised) ) (: L�� t� %} ?V /� / /, l • R
z-
4 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION AII&Z
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME "`f�l PHONE NUMBER
ADDRESS"/�/d4//�E.i' Am. ✓lle- SUBDIVISION NAME
LOT #
DIRECTIONS TO S
i f�P_ ftO (tSe,
rA)
ac b,0 brirle
PR• /mi/e
DATE SYSTEM INSTALLED LoLb NAME SYSTEM INSTALLED UNDER 7, i�qc,N%fira'l,
TYPE FACILITY QST NUMBER BEDROOMS NUMBER PEOPLE SERVED Z
TYPE WATER SUPPLY_ l vu�Li_ . SPECIFY PROBLEM OCCURRING
-5 -h M
DATE REQUESTED IZ�-a INFORMATION TAKEN BY
a
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005200 Tax PIN/EH #: 5744-79-0282
Billed To: Larry. Settlle Subdivision Info:
Reference Name: Location/Address: 495 Pine Ridge Road -27028
Proposed Facility: Residence -Repair Property Size: Date Evaluated: Z — — 0
Water Supply
Evaluation By:
On -Site Well
Community
Auger Boring %� Pit
Public t/
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture groupG
Consistence
Structure
Mineralogy
HORIZON H DEPTH 17
Texture groupG L
Consistence
Structure 15 VA_
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 ,
SITE CLASSIFICATION: ?S
LONG-TERM ACCEPTANCE RATE: , 3
REMARKS:
LEGEND
EVALUATION BY: 6h G n+
J0c, ah
OTHER(S) PRESENT:
I.andsca_pe 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 VFI - Very firm EFI - Extremely firm
-[
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
Mineralog
1:1, 2:1, Mixed
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 05/05 (Revised)