369 Cornwallis Drive Lot 19 �cA—S-2 R-rl 9
AUTHORIZATION NO: 0 0 a DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's c P.O.Box 848
Name: �Y 1 �� E �' _ �` WL;
Mocksville,NC 27028 Subdivision Name:
_?hone# 336-751-8760 I
-Directions to property: ~� d4�►"� ^� ~` Section: Lot:.
AUTHORIZATION FOR
F- , �v �J L•' [�J !1?Tl 1�C.> I�t�c;� WASTEWATER Tax Office PIN:#
—� T - ' YSTEM CONSTRUCTION
1 )aj �� r nnjWAL('1�j '/� Road Name: ��• �1.��Lit�, alp
**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 1) 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.
ENVIRdi4 Nl i HEALTH P fA ST DAT ISS ED
�,—��...r ._a'M1 1,...,.—N-ry-ie'�,.—i..-�-�-n._�T.riT-..'.�.�..a-..— Ju � s- . � Yy y __ p i av �_- .. ___ _..._ _ _._-_ _ - a_• -
0 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
",Pe�altleeys
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Subdivision Name:
Directidns to property: `' t t �' 'i'� 1 'c ' ( Section: Lot:
.. IMPROVEMENT
PERMIT Tax Office PIN:#�� 0 1 _
� Road Name: Zip:
**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 l I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
_ r t. PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPLCIALIST. DA I ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE ALx� #BEDROOMS #BATHS _#OCCUPANTS Ll GARBAGE DISPOSAL: es r No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
0SIx2 riv`x2-(19 n
LOT SIZE TYPE WATER SUPPLYrw001Y DESIGN WASTEWATER FLOW(GPD) " NEW SITE Vl� REPAIR SITE
II dl
SYSTEM SPECIFICATIONS: TANK SIZE I C)%0GAL. PUMP TANK GAL. TRENCH WIDTI ROCK DEPTH 15'- LINEAR FT. -�
OTHER
nT REQUIRED SITE MODIFICATIONS/CONDITIONS: )44-44 .- LN 6,0,✓7_0010 F L--0' IOC LMT P&/� (—/n/E S
( Z{ IMPROVEMENT PERMIT LAYOUT &APPROVED EFFLUENT FILTER& &RISER(S) IF 61' BELOW FIHISRED GRADE
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"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 (336)751-8760.
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OPERATION PERMIT L yy
SYSTEM INSTALLED BY:YQw� X12"
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Gt�MPLi:T. �T
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AUTHORIZATION NO. � OPERATION PERMIT BY: DATE: r
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM CRIBED ABOV AS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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) `
l APPIR A110N FOR SITE EVALUAMON/IMPROVEMENT PERMIT do ATC
Davie County Health Deparbnent
P Environmental Kealffi SmWon 0 [�
Q� P.O. Box 848/210 Hospital Street
Mockaville, NC 27028 61999
(336)751-8760
�N�jRONhf ,
***ZMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE Rc �yn,EA(jH
INFORMATION IS PROVIDED. Refer
� to the INFORMATION BULLETIN for instructions.
1. Dame to be Billed �'�'^a�p—sx cJC!Kc: n /• Contact person
Mailing Address (?(5>3— 8 1 V� Home phone /Q— /O
City/state/zI? C e m m oAs. IVC- a7 old Business phone 7Si —L/O L/O -ex lt ` ` 77
Z. Dame on Permit/ASC if Different than Above
Mailing Address city/state/Lip
3. Application For: U Site Evaluation Improvement Permit/ATC 0 Both
+. system to service: OYHouse 0 Mobile Home 0 Business 0 Industry 0 Other
S. If Residence: //# People l / # Bedrooms # Bathrooms
9-Dishwasher Q'aarbage Disposal Mashing Machine 0 Basement/pluebing O Basement/Do plumbing
6. if Business/Industry/other: specify type # people # sinks
# Commodes # showers # Urinals # Dater Coolers
IF FOODSERVICE: II Seats Estimated Nater Usage (gallons per day)
7. Tppe of Nater supply: 0 ounty/City O well 0 commun
�it
�y
S. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes 1➢�No
1,4
If yes,what type!
***IMPORTANT***CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
/ 1 1
Property Dimerisions: /7S y 39 X l 9 X a�g WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tai Oflice PIN: # L,-,9 !� / -- / �j- 029-7 9tZ 0P-
Property Address: Road Name LOYnI/AIJIS DY
City/Zip MO!/KSV�1��� NC270��
If In a Subdivision provide informatio�n�,as follows:
Name: pt4-
C-ALL
r
Section: Block: Lot: #) Date Property Flagged: J4o1Sz is s-rAw30
This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permit(s)
Issued hereafter arc subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application Is falsilied or changed. I,also,understand that I am rrponsible for all chwTes incurred front
this appU aadon. 1,hereby,give consent to the Authorized Representative of the Dayie County Heal)h peps ent
to enter upon above described property located in Davie County and owned by_ -P.l„ri�1' fij/O�Kk-e r
to conduct ali testing procedures as necessary to determine the site suitability.
DATE 3h /9 7 SIGNATURE 2V
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setback, and septic locations). Y
V n
6-7 Account Na
So
Revised DCHD(07/98) f Invoice No. 5
`-OY h �✓'Gv��i S
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation , q
NAME C N DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence r
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
SITE CLASSIFICATION: EVALUATED BY:
LONG-TERM ACCEPTANCE RAT OTHER(S) PRESENT:
REMARKS:,—S&'- Z f'
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 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(01-901