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105 Vanzant Rd .;f, k � �1,�� P�,�niiiee's { � _.DAVIE COUNTY HEALTH DEPARTMENT �' ' Name: �-- M �r`� �` ��'� ���-� � R w Environmental Health Section PROPERTY INFORMATION j�. ��j (� �/l P.O. Box 848 Directions to property: �" r �/ h1ocksville,NC 27028 Subdivision Name: ���U� `,t�L�� � , [� �' 6-.,.,. Phone#: 336-751-8760 � Section: Lot: ' AUTHORI7.ATION FOR � �f C ..., � WASTEWATER � f � � I��j� r SYSTF,M CONSTRUCTION Tax Office PI # - - ������� � �;� �G}Gtf�l c{,�.� �r /`���t'.,� �� %G,-��� AUTHORIZATION NO: A Road Name: Zip: "` _ **NOTE**This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Forn�/Authonzation Number should be presented ro the Davie County Building Inspections Office when applyina for Building Permits. (ln compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �, �• ;-<; ,� �^+-� a,�'� �' � ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION � �~''�/'��,.��/"�%�'r-�" �� ��� �� IS VALID FOR A PERIOD OF FIVE YEARS. -,;..`--•, .� . /h.1r'F U _ ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE .�� #BEllROOMS � #BATHS i #OCCUPANTS � GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No � � �`��. �, �. � �t i LOT SIZE '� TYPE WATER SUPPLY � � DESIGN WASTEWATER FLOW(GPD) ���G NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �r��AL PUMP TANK�AL. TRENCH WIDTH -� � ROCK DEPTH���,INEAR FT. (t� r OTHER ('�,�. —t.V / d � S( (-t.Cl'��� , /J � _! �,r� l7_1 �S�K���c��('�.- ��.� � �/. • .I �,c REQUIRED SITE MODIFICATION�ONDITIONS: ��" � �J ` � �-�"' �1 <-�' ��i ;�� '�'/� /`�/��'� S J'"7�'' IMP OVEMENT PERMIT LA�'�UT � �i !y � ,.'� —�� r ,��\` � � `L. •--� ,,�1 � —�.• ��r � �/ � -''�-'''cc, t � �'' %. �v�} s� G�5 � � < � �r. i `� 1"t{/ � `��'�— � �.w ` � ` �/ , n 8 ��� `��` � ��`�o � �, r�- o `�, �- ' � � � � �� ,Q���'`� �� - � \-` �` , ' v"'1 �'. C� `� ��, " r'_ � \\� '� � _«-- L ' � (�C_a `} r: ����� `, ��C%� � � � k � �.�` � i ~' � `� I I I FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 830-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT . �)�r� .� �/� ( � SYSTEM INSTALLED BY:__y f�4 4 rfe�r�l�+''" �� �.l � �.. l,�i �// ' /,, ___.�___. � ; j�i ,� ,` =` , ,, ; , . ,� , .�b� ' � j l��- i �-- �� �� �r:\ � �. 'i � 0 `�� �yl✓ /,i --�--�-,,� � � . , � ��l � ,' %'�'Z' ,,i /, , ,�_ �li� ► ' ,,�`� / ,. . f f ,�! % '�., .- I , ,� .� ` ` � � % ` , ,� ,:-' / a� � ' ' , ,, ___.________..-- ��____, � _ _ _.__._ . .._ : -- -- ---------._�..----- ___.__ - '�-�- �� �� � j rA.. . ., . � .� _ .. ._ l-� - -- ; AUTHORIZATION NO. ���� OPERATI I`ON.P.ERMR`-BY"�r_��,,��?�/I''f l r�/� :.i.� �._ DATE: /� I � �,C *"THE ISSUANCE OF THIS OPERA�ION~PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S:CHAP'fER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE TH�4T THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02/02(ReviseA) .f:�I�,.�- r,��;y�? �,,�, ., ?z ,U � C' •� '�,y,• _�.e-.r " .-n',�„-�`�-'�?��'F^�asv'`.a"��+i�+;%i��..I�,sN'4�,��,..,���` ,. : , "y��-�""°".. -- '. ��,,,,�; �'� .�-,;-�,�i _ ,rt"'�:�,:-���`� }4t r.. '`{ � � �� � i!�I� ._ .��L f} 4{ � .�.5�y�^ ^'� fq y'x�1� � � $ 1 I4 ro AY� k/��A A?Pkf�..' � ` , ' ... � �, 'V er' � � � . ,,�, . ' W- .. 2� � "" P�canitt��s x . . � r. �r �E1VgE CO�JI\1'�'I'-�$EAI,�']G$ �IEPA�tTiVI�N r� , . .�- ` �f ,�' Env�ronmental Health Sechon � • PROPERTY INFORMATION �Name:�" �< :� � _��� �� ���� ���-�,,� i P ,P Y:, / "� �� � � �_� ..��. � � ,r P.O. Box_�48 .'„ _ '. ,. . � `� � � C� �✓ ' ..� � E, Duections to' ro ert ` Mocksv�lle:"N +f 27p2g ' Subd�vision'Name � � � , , � . _ , �� j /'�� ����`� � � � � ,,�j �.�, Phone#: 336-751-8760 .' . A - V .< � �• Se�tion: Lot: . , R . 4� �. . , r , . .. _ :.- j AUTHORIZ.A"CI,ON FnR� � ,,, p 1 n ... . '. ' v1'ASTEWATFR ' , '' � ��� � � _�i e1�`j' SYSTF.M'CONSTRUCTION Tax Office PII�1:# � _ �Q�Q�� y �, ; .��;� f��►��a �,i,�.�.&j �� r�'�' :�„_,�d.;��° � .AUTHORIZATION NO: ''� A � � �Road Name. i � Zip: � �.. . . � . � y . .. �,r .. . � R� .a ,�a,Y This Authonzation_for.Wastewater S stem Cc�nstruct�on MUST$E ISSUED b .the Davie:County Environmental Health Sect�on pnor " ,.[ NOT'E , y g l , p ' Counry Building Inspections� , `� ** ** o tssuance of an Build�n Permrts.ThisFonn/Authonzat�on Number should be resenteci to the Davie � mplia Office when a lym�for Bu�ldine Pennits. } i �: ' . . : � p _ � �� wa e Treatment and Di�sposal,S�ystems) ,; ` ��� ' , PP b � .t K ce with Anicle 1 I.of G.S.Cha ter I30A,Wastewater S �stems,Section.1 y00 Se . (ln co . . . � , . � `. � �!'�;� "' �� �� � ***VOTICE*�* ON FOR WASTEWATER CONSTRUCTION �"-��1` , �,.- . '�" � ,' IS.VALID FOR A PERIOD OF FIVE YEARS. � , � ��' �f D.�TE ISS�� � . � � � :c ` THIS AUTHORI7ATI ' E RINV ONMENTAL HEALTH SPE(.IAGIST UED� � , � . , . � �� � • ' ,. i� - '. ; . RESIDE � ., j.. ' � :: ' � PANTS � �- GQRBAGE.DISPOSAL Yes or`No � NTIAL,SPECIFICATION:BUILDING TYPE '�r #BEllROOMS #BATHS #OCCU �. . � I/,.. 4 .� � � II , ,, ' - . - . . _. '. , S . +. COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIET ` #SEATS INDUSTRIAL WASTE Yes or No . � : ,� �, , .� . , ,� .� i � a �< < _ ,� . ,a � LOT S[ZE ��� � TYPE'WATER SUPFLY r ��`��DESIGN WASTEWATER FLOW(GPD) .��G.NEW SITE REPAIR SITE SYSTBM'SPEC �. � . •� � ;. � - " . . � �r - , -, 1 i{ ,�' I. , �''' . 1%` " ,/�,/� j� • ; , �`"� • (:.P ROCK DEPTH f LINEAR Ff � f � T VIFICATIONS TANK SIZE_F� i GAL. PUMP TANK�/�AL�� CH WIDTH •� I � /�� TREN � ; - � � � rf - . . _ / . _ - _ � � ��� �: .r �� �9 ��f ����.�� f OTHER• ��~t —t ti �f Lt,G�t .�fi I �l•�f' t'7 �. Gf�✓f �[`f � �� � ITE MODIFICATIONS/CONDITIONS:__ r/(:� � ' � � � � �� , i{ � � y+ , �n � a�Qut�D s � ' f ��4' ���1 /;'�ilr � �1�� ��'G��� I ��`� %'� �� r5.���'�, ���w.. , : � : - _ . Y , . . - � �{ J Ii_ ' y�',. . � �:,; '��' � r .. . ��. � ._ _ _. � ...._. , .... •.. . , . IMP OVEMENT PERM[T LAY UT . � ii . ' ' � � ` ... . , , .. . , F .� - , 4 , , . i , , , - � . ; .� ,� F� .� I. y - � � . ,..: ,� ; ; . . _ . , „ ' �C � I� v� y - � -„"` ' ,^,^,,.. / ' • , � .. � . . � i , � ' � '�` �� ;- , ii �i I'•'� � /� I f'�.�, ."`^. \ .. r , ' . .r �.. a�.:. . . a�� ' ... .d!d �. ,, �. , � � �� , ' �� �!��1 1 / � � � �� ' � 6' � � � � � � . . , . ` . � � M� I . ' �� _-� �i , . . �, � ; t ;., � . . , �,��;.. . ,;� - _ �. _� -,. , , . . . . � .,� � � � 7 br F � i �w �, ���'� ' ' �i�/ � � ' C.%-- . ` ` � Y - � t�i �,t �'�'� �; �� ��G�' �� Cr�� . : , �� ' �.� �� . � ;��;� � � � � � . , , , . . . /�'" : , '�..; �'�,, . .. . �� ,�p�. � Cj. , t[' � a � ,�„ � / � ��• .�� ; :s . , � � i: . �j`'�.,� � . ' � �'� ' , ^� ,' , , .- . `� �_ ,. . : �' �,. , . � ,� '.. f Q-�, �r �I, _ , '' ���,��'�`*. .' j '$1 ; �(``' � � .-- �� . � . , ,.. ;,-, , : �� ,�� � -:.�r . . . +�; , .,o . � .. �. � p : �' �`� , . , , s �l���="'" �.,�. ' �, . j .. ... � • .. . . ;x �'5� .. . . . � . .X� ., , �. ��•. � � �. s. } �,.. . � ,:j� . ; . , � ; . " , �. ` �,�. ._. ; . . ..,��''�;� C-� � - j� � � ,� �' '� � � !I . .;� , . •I,'" '� � �, � i �. , . , . �� ' � ' _�� � �'i _it - , . � . . . c. . ! � .. - , �:" . ., �.. . .; i � e �� . " ,� .. . _„ ..�: , �'. ,. � .� . . , r3� ii �f �., �. ;: � . . ..,. .. ... . . . _ _ , . _. �r - .. ' � � t�� wti� �_ _ _ . . . . '_ � FINAL INSPECTION OF THIS SYSTENI PLEASE CALL.BETWEEN 8:30�9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. FOR f� . � � ; �: ,'• �, , , . _,. ,._ - „ ,I . . . ,; ° ' OPERATION PERMIT �� � /�J j� . . , .� - �1 � . ,. - ,� SYSTEM INSTALLED BY: . ����� !1l!I�!�I� - ' '' , � � : � p 11 ^ . � - . � � .' , , . ." : � 1�. : : : : . ... , r.. - u •�, _ �,,;,,�-' �� � .. : : . - : � � , / ry .�q� ,4r;'s,. � ../'r'. f l ' ! ; � �� r. " ' , i ; . ,. 2� . If• � � A'^.S ,� ' �f. _ � . � 5.... r • �,l1 � . II � �- yty, `,3. . , S � 1 � + - , . r ± ' i • � .� �.� ;i! i` � fl, F , [ , , ' d . , � _ �, �' —� � . . . • , V, - .. .. . � . , ,�; f� � ,. , , ` r �� � -. ,; . �.Q�''�.� , ��'L� , � . -� � f - � �i: � � � ' �� �� . . ��� _ � � .. � ' ' `��� �� ' � e�� .��d f � � �� . �. . . ' T. �� f �� \,� . . . - , . � '✓' ._. k. ,�( } � '�,' !�` } `^� d� , . . �, � >_ � �4�� �". � ,�'��� �,�"'f� . � , ip�� _ , � � � Y l � � � �./ f� � . :_, ; � v .� � 'f � . � �� ,� �� �...�,�.�, j ;� ; � .�.._���_.�......: _ �� .� ��. ' ��. � �.. . �.�.,�: ,�- :; _ � t ._ � - �� '._..----..,.,�._�- �-, ,r; r_� ` , . ��1 AUTHORIZATION NO. �l � OPERATION PERM3.T.BY:'"'"' . � , ,� � �^" } s a DATE: � +� � ;.: : G = .. , ,""'""..--� , h �` y. ; .-., _ : , ; . , , ._ . i� t , : *"THE ISSUANCE OF THIS OPERATION-PERTviIT 3HALL INDICATE THAT THE SYS�TEM DESCRIBED ABOVE HAS BEEN[NSTALLED IN COMPLIANCE °' � ..` WITH.,ARTICLE 11 OF G.S-C-HAPTER 130A,SECTION.1900"SEWAGE TREATMENTiAND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A- - � GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVENfPERIOD,OF TIME. ;" �� � � ' -�r , . „ • iv • �4'= � `` �� .. , + . . �o�z�R��,�; �t�t�" a�'s y77� �.�.��v �` ����:�l t� - , • ' DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION r/ APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) ��,��/ ME �� e� ��-�--P '��✓� PHON NUMBER � NA o,�,� iti , � E ADDRESS I _U � �� � v� 7 cv�-� (�� SUBDIVISION NAME / LOT # DIRECTIONS TO SITE lP LI � �^ z��t ✓t V Q/r� �u-v1 �/�-G" , / 5�hd�"'�t �-�y� L �� � DATE SYSTEM INSTALLED S NAME SYSTEM INSTALLED UNDER � TYPE FACILITY 3��NUMBER BEDROOMS � NUMBER PEOPLE SERVED TYPE WATER SUPPLY C� SPECIFY PROBLEM OCCURRING ,�;, r (� �.7 `� r DATE REQUESTED � � �� �� INFORMATION TAKEN BY This is to qrtify that the information provided is eorract to the best of my knowledpe,and that I undersWnd 1 am responsible for all chargea incurrsd from this epplication. SIGNATURE OF OWNER OR AUTHORIZED AGENT Flsv.1/93 • � + � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900414 Tax PIN/EH#�. ,s � Billed To: 1�'Srrn'fh Subdivision Info: ���v �� Z�z�� Reference Name: �-�r�.c� �-p S��'^ Location/Address: $ Proposed Facility: Residence Property Size: 5 acres Date Evaluated: ��� Water Supply: On-Site Weil Community Public Evaluation By: Auger Boring Pit �/ Cut ' FACTORS 1 2 3 4 5 6 7 Landscape osition ,(_ Slope % HORIZON I DEPTH Texture grou Consistence Structure ! Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS / RESTRICTIVE HORIZON -� SAPROLITE ./ CLASSIFICATION LONG-TERM ACCEPTANCE RATE .J7 SITE CLASSIFICATION: � �_�• EVALUATION BY: ��V�'`^X���^'� LONG-TERM ACCEPTANCE RATE:_ � � S OTHER(S)PRESENT: C�l �`e�-f YJ REMARKS: LEGEND Landsc�e Position . R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope T�x2ur�. 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 CnNSI�TF,N . . �'IQ1S� VFR-Very friable FR-Friable FI-Firm VFI-Very�rm 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 $.�ructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Minerato�v 1:1,2:1,Mixed ���� �"� 7� Notes Horizon depth-In inches �.r—� v, � 7,2, ��o 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) TTAR -T.nna-tP.rm a�rPntan�P ratP_ aal/rla��/ft� T�l�TTT hC/hC m__.___��