246 Turkeyfoot Rdit
Pezmittee's DAVIE COUNTY HEALTH DEPARTMENT
Name: ftr fljOdd Environmental Health Section PROPERTY INFORMATION
�,p P.O. Box 848
Directions to property: 11�� Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
�-c O +'` Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION tj
Tax Office PIN:#� - -
AUTHORIZATION NO: 002857 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 cgl$ppance with Artick 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEALTH SPECIALIST
-�*NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
DATE ISSUED If
Permittees DAVIE COUNTY HEALTH DEPARTMENT
Dame:, `5 p1'1 Environmental Health Section
g P.O. Box 848
PROPERTY INFORMATION
Directions to property: _! (A J T �� 1 Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section:
AUTHORIZATION FOR
°� j� ( WASTEWATFR
t > i" .✓i Tax Office PIN:#
SYSTEM CONSTRUCTION ,
AUTHORIZATION NO: 002957 A Road Name:
Lot:
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 Forrn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In cgmpl)ance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f+'✓tl f''� 6,� . ' ,r M" ""IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED (.•j
RESIDENTIAL 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)') NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE _ GAL. PUMP TANK I AL. TRENCH WIDTH Ite ROCK DEPTH ! 1 LINEAR TV
OTHER ►� % f
r x; r
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
J, �LI,rO�
-I _ IF ; V..
IIFOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. tl
OPERATION PERMIT fl
SYSTEM INSTALLED BY:
0C. Vrvu '
1
AUTHORIZATION NO. i OPERATION PERMIT BY: 4 zfi DATE: ;?--
`%
-r
1C�y d�'t
*"THE ISSUANCE OF THIS OPERATI N P1RMIT SIPAI I 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 02/02 (Revised) � / �/1 P / 17 .� , � �A t , . �� �j ,{ / V / /.,5D f/
l.L (f 1 I J.iv V c (�' Q
4 Permittees` ¢ i DAVIE COUNTY HEALTH DEPARTMENT
N irnF: r Y: 3 _ i Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property:�a1 E� .� Mocksville NC 27028 Subdivision Name:
p Phone #: 336-751-8760
Section:_
AUTHORIZATION FOR
WASTEWATER
Lot:
f ti Tax Office PIN:# - -
SYSTEM CONSTRUCTION
AUTHORIZATION NO: d 0 2 S 7 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 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 a, L # BEDROOMS _ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
—y
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE _ _ # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY '( DESIGN WASTEWATER FLOW (GPD) 3(�!� NEW SITE REPAIR SITE f'
r> t
SYSTEM SPECIFICATIONS: TANk SIZE J':G�L.,e"PUMP TANK GAL. TRENCH WIDTH "3r' ROCK DEPTH LINEAR FF. .7('
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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.
OPERATION PERMIT
` SYSTEM INSTALLED BY:
---�.. C A
a�Ck
aCo (�
loa`
I � �� -�
Leo
AUTHORIZATION NO. OPERATION PERMIT BY: ��q/ DATE: —�
**THE ISSUANCE OF THIS OPERATION P8RMI 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. '% �/ 7
DCHD 02/02 (Revised) � i✓ -- � G `% ! 1 " (- ICi �\ C% v � / �! �0 (%
fiee,rb - V. O
r• ;
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) [�
NAME 'Ck y P 561' PHONE NUMBER 7 �7DS
ADDRESS l ul"T7J6f yw SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED I L760 0 NAME SYSTEM INSTALLED UNDER
TYPE FACILITY a l4y - _NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRINGG'�)��
DATE REQUESTED _"INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I
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
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH �-
Texture groupC
Consistence
Structure
Mineralogy
HORIZON H DEPTH
Texture roup
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture Eroup
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-T,ERM ACCEPTANCE RATE: 0-1 d
REMARKS:
LEGEND
EVALUATION BY:
r
OTHER(S) PRESENT:
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 VFI - Very firm EFI - Extremely firm
M&I
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
Mineral=
1:1, 2:1, Mixed
Natra
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)