112 Timber Creek Road Lot 8-:
AU7 �40RIZATION NO: Q 9 8 7 DAVIE COUNTY HEALTH DEPARTMENT
V'
r ' Environmental Health Section PROPERTY INFORMATION
PerctMee's /J P.O. Box 848
Naine: iG/(� �i9�$'ot1 �5 Mocksville, NC 27028 Subdivision Name:
f �� Phone #: 704-634-8760
Directions to property: t.1 � "_. %r Section: Lot:
AUTHORIZATION FOR j�� /
WASTEWATER ffice PIN:#
SYSTEM CONSTRUCTIO�i b�'
(` Road Name: f �-� (-T� It l- Zip: r Li (7
**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)
/J� p ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/� �D �J • �'-� 7-9 7 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
"A IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION'
V'Pxrrnttees` /
N e: +% i . An�;rten9't < ,`-5Jr-
Directions to property:
Subdivision Name: -
Section: f t� Lot:
IMPROVEMENT L t L., -
PERMIT Ta �ffice PINN !�t' _
Road Name: C+� ^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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
SO,a���1 • p '�7� / 7 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 _j"i # BEDROOMS # BATHS —,4— # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �` �TYPE WATER SUPPLY 4-1,� DESIGN WASTEWATER FLOW (GPD) —21,13 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE �C��D GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH � I"LINEAR FT. JW)
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
cAd"r dA0 R'a
"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.
OPERATION PERMIT
SYSTEM INSTALLED BY:
)e0sx`oq
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 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 05/96 (Revised)
'?bw 01AP
1 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED!
PROPOSED FACILITY _ PROPERTY SIZEi�
SUBDIVISIONYL�e �� r� l� ROAD NAMEu!b��.
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
Public G' -l"
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
e
Mineralogy
A. /
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 211:a 7f6 rt�"
LONG-TERM ACCEPTANCE RATE: "3
REMARKS:
DCHD (01-90)
EVALUATION BY: A `/
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 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
SC - 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
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7. Type of water supply: County/City ❑ Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes ❑ No
3'
PROPERTY INFOIRMATION�REQUIRED *** IMPORTANT *** A PLAT OF THE,PROPERTY MUST IX
II
:` -SUBMITTED WITH TRIS APPLICXT')N`:
Property Dimensions: /10 1 WRITEDIRECTIONS (from -
1 ; Mocksville) TO PROPERTY:
r Tax Office PIN ".#
Property Address: Road Name 64 i Cc 6' le 0 - 1
1 6� A) CC -6 A?Q
City/Zip 40 rA R)C a 700 6 �
1 ,� SIL F Cd
If in Subdivision provide information, as follows: 1
Name:rnde�-
1 Q/�U Pf%.rLri 0 /J
Section: Lot #: A-- 7-
1
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 cr•,sent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Da -!ie County
nd owned byr ,��cJ6/1G %� T'n� to conduct all testing procedures
as ne e° 38rj to determine the site suitability
DATE— t LI —7
Revised DCHD (06-96)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC
..
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(704) 634-8760
r.
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED. INFORMATION IS PROVIDED.
1.
Name to be Billed
�� C/C ,�/�tI /�= ct tJ �c� 5 �" Contact Person
t
I l Tag Address(.CJi-'Jea
Z7b✓'.L% Home Phone — 7,5 7
icy/State/Zip
99f -7a "
, //ll)GkS�//t-LE N • Business Phone .:
2.
Tame on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3.
Application For:
/
Site Evaluation ❑ Improvement Permit & ATC Z1- Both
4.
System to Serve:
House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5.
If Residence:
# People # Bedrooms # Bathrooms
❑. Dishwasher
❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No'Plumbing
6.
If,Business/Other
Specify type # People # Sinks
# •Commodes.
# Showers # Urinals # Water Coolers
If Foodservice:::.
# Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City ❑ Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes ❑ No
3'
PROPERTY INFOIRMATION�REQUIRED *** IMPORTANT *** A PLAT OF THE,PROPERTY MUST IX
II
:` -SUBMITTED WITH TRIS APPLICXT')N`:
Property Dimensions: /10 1 WRITEDIRECTIONS (from -
1 ; Mocksville) TO PROPERTY:
r Tax Office PIN ".#
Property Address: Road Name 64 i Cc 6' le 0 - 1
1 6� A) CC -6 A?Q
City/Zip 40 rA R)C a 700 6 �
1 ,� SIL F Cd
If in Subdivision provide information, as follows: 1
Name:rnde�-
1 Q/�U Pf%.rLri 0 /J
Section: Lot #: A-- 7-
1
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 cr•,sent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Da -!ie County
nd owned byr ,��cJ6/1G %� T'n� to conduct all testing procedures
as ne e° 38rj to determine the site suitability
DATE— t LI —7
Revised DCHD (06-96)
**NOTE** . his�Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
t issuance"of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
,Offic) when applying for Building Permits.
(In compliAdceith Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r • *'� ! " f C r IS, VALID FOR A PERIOD OF FIVE YEARS.
ENVIRQNMEN jEi'l tALTH SPECIALIST DATE ISSUED
RESIDENTIAL ICATION: BUILDING TYPE BEDROOMS _ #BATH #OCCUPANTS GARBAGE DISPOSAL: Yes or No
`1��iCOMMERCIAL LQATION: FACILITY TYPE t. E # PEOPLE/�HIFr #SEATS —_-- NDUSTRIAL WAST Yes or No
v ( —
k I � t6/ 0 I
LOT SIZE, D' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW ( PD) NEW SITE REPAIR SITE '
I i x. '► ,r
SYSTEM SPECIFICA IONS: TANK SIZE GAi . NK GAL. TREK' H WIDTH ! ROCK DEPTH LINEAR
i
i�
REQUIRED SITE MO
r -
rtn
�DITIONS:"
IMP
OVEMEN715ER
YOU
Permittee's- �f t�
'\'N
+ f AVIE COUNTY HEALTH DEPARTMENT
`
Name: `- `i
' i ,
Environmental Health Section
PROPERTY INFORMATION
Directions o property:
�'
P.O. Box 848
Mocksville, NC 27028
Subdivision Name:
f
Phone #: 336-751-8760
( L N", i
Section:
Section: Lot:
a
AUTHORIZATIONEOR
WASTEWATER
a {
0030 1 1
SYSTEM CONSTRUCTION
#
Office PIN:Y
7(
AUTHORI�ON NO:
A
4
Road Name: Zip: ') 06 -`
**NOTE** . his�Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
t issuance"of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
,Offic) when applying for Building Permits.
(In compliAdceith Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r • *'� ! " f C r IS, VALID FOR A PERIOD OF FIVE YEARS.
ENVIRQNMEN jEi'l tALTH SPECIALIST DATE ISSUED
RESIDENTIAL ICATION: BUILDING TYPE BEDROOMS _ #BATH #OCCUPANTS GARBAGE DISPOSAL: Yes or No
`1��iCOMMERCIAL LQATION: FACILITY TYPE t. E # PEOPLE/�HIFr #SEATS —_-- NDUSTRIAL WAST Yes or No
v ( —
k I � t6/ 0 I
LOT SIZE, D' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW ( PD) NEW SITE REPAIR SITE '
I i x. '► ,r
SYSTEM SPECIFICA IONS: TANK SIZE GAi . NK GAL. TREK' H WIDTH ! ROCK DEPTH LINEAR
i
i�
REQUIRED SITE MO
r -
rtn
�DITIONS:"
IMP
OVEMEN715ER
YOU
...�
Pv
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l
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GtAiSPECTION�t�f'��IvTI'LEASE CALLBETWEEN'8 30 = 9:30 A.M. ON THE DA OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERtTION PERMIT
t SYSTEM INSTALLED BY:�
t
___ .ice----'—_'___ �.� ^ �__..'__�--�.—�. �• _
- - --------
I 1 \,J `
v � _
A ,
_ v f: C—
AUTHORIZATION O. OPERATION PERMIT BY: �— `) >" DATE:
r C
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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)
a
,.n
DAVIE COUNTY HEALTH DEPARTMENT 40 ®
Environmental Health Section SECTION_ LOT
Soil/Site Evaluation
APPLICANT'S NAME '1 z zy Y -S 6y✓ DATE EVALUATED
PROPOSED FACILITY ; 114, PROPERTY SIZE �'h✓fes/ l
SUBDIVISION l i Mke- l" C re -(2- ROAD NAME
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
Public c%
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
(, .I- .C,
Slope %
HORIZON I DEPTH
"
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
77
Structure
-1
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
,S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
EVALUATION BY:
OTHER(S) PRESENT:
REMARKS:
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
SC - 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 (O1-90)
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