157 Sandpit Road Lot 26AUTHORIZATION NO. '1127 DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section PROPERTY INFORMATION
ermittee'S /` �% r,, P.O. Box 848 �----? I
Name: `'' '��! 4 •*t ���%I E L r NC 27028 Subdivision Name: 7 jye7zyciy k)
��e }� � �f Mocksville,
Phone #: 704-634-8760
Directions to property: t
Section: Lot:
AUTHORIZATION FOR�j,
WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:#.6�d 6.3-
i Road Name: T°2 :
l p_
**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
10
i` S' ,< . ' f".fj,�' / • - - ✓/� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
_'"`M�"1•'f"�°I)to�';`�"�W7✓�?`'i�'Y'•t?"�^'��.R.tw'^""�'-�.''�rv: ,n,•y..,w•,�..: �.k,+''�r^'tr�..,�,,r-a�l.-.�+-• . �./ Q
DAVIR COUNTY HEALTH DEPARTMENT D
{ , ROVEMENT AND OPERATION PERMITS 'PROPERTY INFORMATION-,.. '
� p
e:, i "Subdivision Name:. ' I14if !#,,
Directionb„to p PertY: r , � � .: r .t { ecti, n: Lot. Ag
•IlVIPROVIINENT
Tax.Off`ice PIN:#P- +�
+.�. P.
r Road Name: r
r: r•
**NOTE** This Improyemegt Permit DOES NOT authorize the consti tion or installation of a septic.tank system or any wastewatersys tem
AUTHORIZATION FOR WASTEWATER SYSTEMCONSTRUCTION must be obtained from this Department prior to the
w
consctiontinctallation of a system of the issuance of a building -permit y
;(Incompliance. with Article 11,of G.S. Chapter. 130A, -Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** Tfus PERMIT is SUBJECT TO REVOCAMN IF SUE
PLANS OR THE EVTF,NDED.USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST ' DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERA'IIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS 4
• , - � � ' #,OCCUPANTS GARBAGE DISPOSAL: Yes or.No „
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF/SHIFT #, SEATS INDUSTRIAL WASTE: Yes or No
�! TER SUPPLY DESIGN WASTEWATER FLOW (GPD) t?6l� NEW SITE !/ REPAIR SITE
LOT SIZE C .TYPE.WA
SYSTEM SPECIFICATIONS:TANK SIZE /QD� GAL. PUMP TANK GAL. TRENCH WIDTH CIV
/ROCK DEPTH�� LINEAR FT.
•• OTHER • - •
REQUIRED SITE MODIFICATIONS/CONDITIONS:
-Pp-
avRovEmENT PERMIT LAYOUT.
P ,q�4.
.**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 PAL ON THE DAY OF.INSTALLATION. TELEPHONE # IS (704) 634-8760.
O N PERMIT fl f
a" SYS INSTALLED BY:
AUTHORIZATION NO. =��— OPERATION PERMIT BY:. DATE:
*.*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED. IN COMPLIANCE
WITH ARTICLE i 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 03/96 (Revised)
•
0
APPLICATION FOR SITE EVALUATIONAMPROVEMENI I& ATC
Davie County Health Department' Q
Environmental Health Section
P.O. Box 848 6 i
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
-DV � r3r-,5:,v ham,,n
1. Name to be Billed /G k c .� I� �M >n Contact Person _ c�
Mailing Address 3 �d S P, G M 4 �/�) d . Home Phone (l-Cj 7Z
City/State/Zip - M s ✓ A_ e- N C 2 7(5:2- V Business Phone cI `7 k— 2 70 1
2. Name on Permit/ATC if Different than Above AUJ C' /-rt-9,�,� /-? u :'L CZi',JJ _.§� l PC -
Mailing Address ivt City/State/Zip
3. Application For: [ Site Evaluation [Improvement Permit & ATC
4. System to Serve: [_,�Ouse [ ] Mobile Home [ ] Business [ ] Industry [
5. If Residence: # People # Bedrooms # Bathrooms_
[ ] Washing Machine [ ] Basement/Plumbing [ asement/No Plumbing
1 Other
ishwasher [ ] Garbage Disposal
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water age (gallons per day)
7. Type of water supply: [ ] County/City [ ell [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [�
If yes, what type?
,MAL UK J L L P- YL -AN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #-- - S% S 7G Lk 70 L) /�cJ
Property Address: Road I�ame_���" Fi���C� � TV � AJ
L ID Tb ZLV
City/Zip Mo r k r,. _ t To V�J k ; ti tJfl LG �o/ L
If in Subdivision provide information, as follows: )�?n '/ a L r- L_
Name: RAI s ���%a`.'L S —Fa S-9 �,L /moi Ed 0 0 L t r T
Section: Lot#:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by �O d ,57,v, - to conduct
DATE J / - t-' - g7 7 SIGNATURE
Revised DCHD (06-96)
ing procedures as necessary to determine the site suitability.
THIS :V" A MAY $E USED. FOR DRAWING YOUR SITE PLAN:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME Z/
ADDRESS
PROPOSED FACIILTY ".L-10 t(57 e -
Water Supply: On -Site Well L____ _
Evaluation By: Auger Boring
r Ogg
41
•
DATE EVALUATED -'?/ VA'
PROPERTY SIZES
LOCATION OF SITE!
Community
Pit
Public
Cut
FACTORS
1 2 3 4
Landscape position
L
Sloe Z
HORIZON I DEPTH
Y
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
i
Structure
44X? Ak
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 ►EVALUATED BY: TA��
LONG-TERM ACCEPTANCE RATE: ,2 OTHER(S) PRESENT:
REMARKS: G - � s K
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- Vl---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
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
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