115 Spry Ln Davie County Health Department
}, ENVIRONMENTAL HEALTH SECTION
P.O. Box 6b
c1
o 5
;{ Mocksville, N.C. 27028 Rh� v7 �0
THOR
AUIZAHON FOR WASTEWATER SYSTEM CONSTRUCTION
s
(Issued in compliance with Article 11 of
r G.S. Chapter 130A, Wastewater Systems) r
f ?•9tiaY,
***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.*** '
NAME �,O R� W AP.�S t'1 1" DATE 1 O / AUTHORIZATION NUMBER
2 �3 19
MANE ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATIW
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
IL
**OWICE*** THIS ALUHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
� s
ENUM ENTAL HEALTH SPECIALIST DATE,
DCHD' 10/:95
y
• k DAVIE COUNTY HEALTH DEPARTMENT (YV
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**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 6.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME �j,�RI C�W AR�.� C1\� PROPERTY ADDREDATE
LOCATION �� ��csc�. Chcss � y�e"` ►,,a. Oce baa 1� Q sc�
SUBDIVISION NAME °r `"'�~ LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE ~ # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Ye No
COMMERCIAL SPECIFICATIQ,Y: FACILITY TYPE'. # PEOPLE # PEOPLE4SHIFT 4# SEATS INDUSTRIAL WASTE: Ygs/N�o
a!►,
LOT SIZE •�7-G� TYPE WATER SUPPLY Qou � DESIGN WASTEWATER FLOW (GPD) 360 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK,SIZE j 00 KW TAM#(' GAL. TRENCH WIDTH,, 3 1� ROE Z'DEPTH �I� LIMEAA FT. : d0�
OTHER
REQUIRED SITE MIODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE P'W'OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM.CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE"SYSTEM.
C y o
dud ' P
1
Ss
s
r IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE DOTHE 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 THEiDAY:OF INSTALLATION. TELEPHONE # I5 (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY �.�.o�..
_a ` CU a N
1
131 r1rj
AUTHORIZATION N0.dj91 OPERATION PERMIT BY \ DATE " 10 ' 96
**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 10/95
4
IE c� [S aVME
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE �I
Davie County Health Department OCT '
_ Environmental Health Section
3 [995
P. O. Box 665 -
Mocksville, NC 27028
1, Application/Permit Requested By Loki. - --�J��d5 ! l t 0-77 7 6 �
Mailing Address L -7s q Ki✓ / Home Phone
LA) - j�,ZC '1 ((13 Business Phone
2. Name on Permit if Different than Above
3, Application for: d General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House OLMobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms.
Washing Machine
No. of Bathrooms ❑ Dishwasher t
Dwelling Dimensions 5C-P A a ❑ Garbage Disposal f
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals ;
I
No.of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7.'Type of water supply: Public ❑ Private ❑ Community
8. Property Dimensions a OLCT Sewage Disposal Contractor
t.
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No
If yes, what type?
( I
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
t
revocation, if site plans or the intended use change. Effective October 1, 1989.
PROPERTY INFORMATION REQUIRED:
Dire tions to Property: Tax Office PIN ra a 1
Road Mame rl/ ROT
Box // (if available) j
City moc► ksy� �ilQ �.
D u.r
This is to certify that the information provided is correct to the best of my knowledge, and 1 understand I am responsible for all charges
incurred from this application.
s , Edu, J0,C10
DATE SIGNATURE
j
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 2. 1 DO NOT OWN the property.
If you checked Box #2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative aavie Count Health Departrgq
nt to ante upon above described
property located in Davie County and owned by _ ?
to conduct all testing procedures as necessary to determine said site's -suitability for a ground absorption sewage treatment
and disposal?sys C/.JDI
DATE SIGNATURE
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EDDIE BURCH, JR.
D.B.167. PG.780 I .
ontm PirnjApn I-InWAR(1 rpr+;fv i•hnf ... .....
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation /
NAME n 01R% t `� 4 A )4 11! DATE EVALUATED
ADDRESS A � PROPERTY SIZE
PROPOSED FACIILTY �\ 9 LOCATION OF SITE
Water Supply: On-Site Well _ Community Public
Evaluation By: C�fjl Auger Boring L� Pit Cut
FACTORS 1 1 2 3 4
Landscape position
Sloe Z __ 2--
-6
HORIZON I DEPTH '
Texture group t"1.- C L
Consistence k -M
Structure Q Z
Mineralogy1
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 • S,
LONG-TERM ACCEPTANCE RATEJ 14 -
SITE CLASSIFICATION: �'S' EVALUATED BY: �� `�
LONG-TERM ACCEPTANCE RATE: • OTHER(S) PRESENT: dP�"� `k1N_5_
REMARKS: Catom•. t Gyc-ar�`
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Footslope 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-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
.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(01-90)
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