869 Gladstone Road Lot 3AUTHORIZATION NO: Q 6 % O DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Pemitttee's° , /I / P.O.; Box 848
Name (?li�G�G� Mocksville, NC 27028 Subdivision Name: ��/1�(1�j
Phone #: 704-634-8760
Directions to property: Section Lot J
AUTHORIZATION FOR -
WASTEWATER' Tax Office PIN:#d .9 -.�
SYSTEM CONSTRUCTION ON ` %e `/
' Roa��me: e4a t57DNeZip. a7oap
**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 FomJAuthorizationNumber 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 ."
+P� •, fiS /� IS VALID FOR A PERIOD OF FIVE YEARS."
E�VIRONMENTAL HEAMH SPECIALIST ' ,DATEISSUED
DAVIE COUNTY HEALTH DEPARTMENT
a' r= IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pemu tee's /
Name. ' j t5.Gl/1 Subdivision Name:y
DirectioUtopr8perty. Section: ..�Lott:/ Opr�
IMPROVEMENT
PERMIT Tax Office PIN:0 /y� 3s 1!n7
RoadN e:[1—w d57<11l� h p
**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
constructionlinstallation 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
f 3'-L4+X w s c'[�✓ )f f `. J �/% 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 f1 # BEDROOMS -? # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE #PEOPLE/SHBTr-'#11 SEATS_ INDUSTRIAL ,WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) �411W SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE,&d—LQ GAL. PUMP TANK - GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
i' OTHER
. REQUIRED SITE MODIFICATIONS/CONDITIONS: -
F
-"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) 6348760.
OPERATION PERMIT - -
SYSTEM INSTALLED BY:
F
�!� / I
AUTHORIZATIONNO. OPERATION PERMIT BY: /` ✓CY� DATE: L /
"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)' - -
V1 t
�. Application/Pennit I
Mailing Address
I
J,t
'
l ,
Evaluation ❑ Septic Tank Installation Permit
I t
S
❑ Place of Public Assembly
t
Y.
❑ Unknown
{
.
2
•
_
❑ Basement(Plumbing
No. of People
/o
41
� I r
❑ Washing Machine
v
t
25
q/'.•
❑ Dishwasher
t
i Dwelling Dimensions
_
❑ Garbage Disposal
-6. if business, Industry, place of public assembly, other:
4} i pl
No. of People Sewed -
No. 01 Sinks
,
No. of Commodes
No. of Urinals
No. of Lavatories
No. of Water Coolers
• No, of Showers
x'
Water Usage Figures
7. Type of water supply: Public
❑ Private
❑ Community
-,
8. Property Dimensions'
•� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this
sytem is Intended to serve? ❑ Yes ❑ No
If yes, what type?
V1 t
�. Application/Pennit I
Mailing Address
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT
Davie County. Health Department
Environmental Health Section
P.td Box 665
Mocksville, NO 27028
u� �11a r r
" Home Phone
1 I .
r6lK Business Phone = r
2. Name on Permit If diH�ent than Above
t rv.
'
'. 8. Application for. ❑ General
Evaluation ❑ Septic Tank Installation Permit
4...System to Serve:_ yl House
❑ Mobile Home
❑ Place of Public Assembly
t
Y.
❑ Unknown
f
.
2
•
_
❑ Basement(Plumbing
No. of People
/o
. ,No. of Bedrooms
❑ Washing Machine
v
t
25
1
❑ Dishwasher
t
i Dwelling Dimensions
_
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT
Davie County. Health Department
Environmental Health Section
P.td Box 665
Mocksville, NO 27028
u� �11a r r
" Home Phone
1 I .
r6lK Business Phone = r
.NOTE:_ ImprovemeAI Permits shall be valid for a period of 5 years from date Issued. Improvements Permits are subject to
revocetidn, �f site plans or the Intended use change. Effective October 1, 1989.
Directions to Property:
This Is to certify that the Information provided Is correct to the best of '�
nowleage, ana I uncerstena I am responsloie Tor an cnarges
Incurred from this appllc t 2
DATE/ SIGNA IQRE�
CONSENT EQB SASE EVALUATION 14. IM DONE til! ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: I ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
It you checked Box #2, the rest of this forth MU &I 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 D9vie County and owned by
to conduct all testing (procedures as necessary to determine said site's suitability for a ground ab rpUon sewage treatment
and disposal system,
DATE SIGNATURE
2. Name on Permit If diH�ent than Above
'
'. 8. Application for. ❑ General
Evaluation ❑ Septic Tank Installation Permit
4...System to Serve:_ yl House
❑ Mobile Home
❑ Place of Public Assembly
❑ Business ❑\Industry
" ❑ Other
❑ Unknown
S. If house, mobile home: Subdivision �y/%A!/n:01,
//
➢5'
Section Lot #
_
❑ Basement(Plumbing
No. of People
❑ Basement/No Plumbing
. ,No. of Bedrooms
❑ Washing Machine
No. of Bathrooms rZ
❑ Dishwasher
t
i Dwelling Dimensions
_
❑ Garbage Disposal
-6. if business, Industry, place of public assembly, other:
Specify type
No. of People Sewed -
No. 01 Sinks
,
No. of Commodes
No. of Urinals
No. of Lavatories
No. of Water Coolers
• No, of Showers
x'
Water Usage Figures
7. Type of water supply: Public
❑ Private
❑ Community
-,
8. Property Dimensions'
•� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this
sytem is Intended to serve? ❑ Yes ❑ No
If yes, what type?
.NOTE:_ ImprovemeAI Permits shall be valid for a period of 5 years from date Issued. Improvements Permits are subject to
revocetidn, �f site plans or the Intended use change. Effective October 1, 1989.
Directions to Property:
This Is to certify that the Information provided Is correct to the best of '�
nowleage, ana I uncerstena I am responsloie Tor an cnarges
Incurred from this appllc t 2
DATE/ SIGNA IQRE�
CONSENT EQB SASE EVALUATION 14. IM DONE til! ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: I ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
It you checked Box #2, the rest of this forth MU &I 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 D9vie County and owned by
to conduct all testing (procedures as necessary to determine said site's suitability for a ground ab rpUon sewage treatment
and disposal system,
DATE SIGNATURE
DAVIE .COUNTY HEALTH DEPARTMENT
Environmental Health Section' r
Soil/Site Evaluation
NAMED/j���y� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE w�i90��6,VP
Water Supply: On -Site Well - Community Public-
Evaluation By: Auger Boring - Pit 6,,-' Cut, -
FACTORS
12 3 4
Landscape position L
G
Slope $'
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
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 i
SITE CLASSIFICATION: EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: 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.f'rm
.. - 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 AHK -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 watet 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