116 Winchester Road Lot 13AUTHORIZATION NO: 0529 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permitte,e'� P.O. Box 848. ,QQ
Name: &, ?'t ' I,714-I'SaA Mocksville, NC 27028 Subdivision Name:
Directions to property: 4_rX4_ 'rr 4, i Phone #: 704-634-8760 Section: Lot: �sry
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
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 I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
> le,! r''f 11%: IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTErSPECIALIST DATE ISSUED
x"9°""`°"',1 z',T"" ;Y?^!.•;;. �`�°F• fi -,,„ gam/—;��/
' DAVIE COUNTY HEALTH DEPARTMENT
}\ { IMPROVEMENT•AND'OPERATION�IPERMITS PROPERTY INFORMATION
YCL�
.Name t^4 jo-
4ubdivision Name:
Directions to property:, 11. 16 Section:_ Lot:
.EMPEOVEMENT
RMTT " -
" Tax Office PIN:#
M ra Road Name Zip:
. **NOTE** This Improvement Permit DOES NOT authorize the constriction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must b#obtained from this Department prior to the "
construction/mstallation of a system, or the issuance of a building permit.
(In compliance with Article .11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�• ***NOTICE*** THIS PERMIT IS,SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL-HEALTH SPECIALIST. DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM:
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
y
LOT SIZE C : TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW STIE_i/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK Suze, GAL.. PUMP TANK • GAL. TRENCH WIDTH ?C ROCK DEPTH LINEAR FT,D
..REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*"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 (704) 634-8760.
"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 BETAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY;GIVEN PERIOD OF TIME.
DCHD 0996 f i viaed)
e
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PER
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
JUL 1 1 1995
1. Application/Permit Requested By
Mailing Address a 12 S 4,01,06 Ahl ►/,--� L Ill • Home Phone 7:5' 7
/%O CAC,S V C -A-) -76 - Business Phone
2. Name on Permit if Different than Above
g.-_ Application for: )(General Evaluation Septic Tank Installation Permit
4. System to Serve: > 1 Houses ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry / ❑ Other ❑ Unknown
5.' If house, mobile home: Subdivision �� a 9� %6'`�" Section Lot #
/41
❑ Basement/PlumbingNo. of People �N CLUB /�/�' /t%E/�O
O Basement/No Plumbing
Ci1J Vic. (iA�C.Cx} /-�D�
No. of Bedrooms _ El Washing Machine
No. of Bathrooms ❑Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: Public ❑ Private
8. Property Dimensions ZeI7-5, 3J C1 — Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes ❑ No
p Community
"NOTE: Improvements Papits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:.
7�Y E r/2/614 2-, OP,6 % 641J.0
This is to.certify that the information provided is correct to the
Incurred from this application.
9 =7
DATE
of my knowledge, and 1 understand I am responsible for all charges
SIGNATURE
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 of the Davie County Health Department to, enter upon above described
property located in Davie Cpunty and owned by
to conduct all testing procedures as necessary to determine said site's suitabilityor a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1193)
. - DAVIE COUNTY HEALTH DEPARTMENT ll�
Environmental Health Section
Soil/Site Evaluation
NAME �� L
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED C 4_2
PROPERTY SIZE 7 iqL
LOCATION OF SITE
Community
Public 9i_
Evaluation By: Auger Boring Pit L1____ Cut
FACTORS
1 2 3 4
Landscape position
Lti
Slope Z
-�
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
.0 O ;P -
Texture rou
Texture
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: ,J
LANG -TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: .I�
OTHER(S) PRESENT:
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 <;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V}. -y 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
Mineralomy
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