138 Shady Grove Lane Lot 3cAlC•�•rr. ..-rr'_�... .•.:: (-a.. �.rr-a--rv-r'•r � .
-.AUTHORIZATJONNO: 0734, DAVIECOUNTY .HEALTH DEPARTMENT
Environmental Health Sect PROPERTY INFORMATION
Pes -/ / ,�- P.O. Box 848
NaRi /5 �1Lt1 P %lit �FQ/u Mocksville, NC 27028 Subdivision Name: / v e
l —r / Phone#:704-634-8760 .
Directions to property: /� Section: Lot:
AUTHORIZATION FOR
-. WASTEWATER 'Tax Office PINr
SYSTEM CONSTRUCTION :#/t �+
Road Name: SHQ (7r0 vpo 6
**NOTE** This Authorisation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This FormiAuthorization 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
{( ;tL.fS'`b _, -- ISVALIDFOR APERIOD OFFIVE YEARS.
ENVIRONMENTAL HEALTH. ECIALIST DATE ISSUED
�•� 'e� F Jnb.""Cil1i e1cT13 A., '1 Yi%'krT I �+ �tA p:. Y1� `r%f PR``1,�,h-'4.h"�"1N } ^l YahvCW . Vp'p,flAli `u f s{trjz,/jjj���{L''ny.
DAVIE COUNTY HEALTH DEPARTMENT
��' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION '
"a;nnr%F� T7r'r///n l
e Subdivision Name i a in d e^
Directionato.property: '/t4 ` A�111 Section: / Lot: .4
V, IMPROVEMENT ra
PERMiT Tax Office PIN:#_ tl
Road Name:yyap: 4
**NOTE** This Improvement Permit DOES NOT!authorize the construction oc 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*** TMS PERMIT ISSUBJECTTOREVOCATION IFSITE
�,.W frJ) _•Y Ji `% PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTHSPECIAI IST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE, # BEDROOMS _ T # BATHS �? # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT . # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE/-&VZd— TYPE WATER SUPP
/L
eY
,, �,� DESIGN WASTEWATER FLOW (GPD), ?'V'
,? NEW SICE� REPAIR SITE
&P
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK - GAL. TRENCH WIDTH?,. ROCK DEPTH /2 LINEAR FT. aZJ 7'
- OTHER
- REQUIRED SITE MODIFICATIONS/CONDITIONS:
"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.
AUTHORIZATIONNOD
OPERATION PERMIT BY:. � � � DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11,017 G.S. �HAPTER 130A,, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SY§TEIv1 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME,
DCHD 05196 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME
6
PROPOSED FACILITY
SUBDIVISION
Water Supply: On -Site Well
Evaluation By: Auger Boring
SECTION LOT_.
DATE EVALUATED
PROPERTY SIZE
ROAD NAME 1. (Y
Community Public
Cut
FACTORS 1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
,Mineralogy
HORIZON II DEPTH
b /
Texture group
Consistence
T
Structure
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: t
qM
aanro1-m:
EVALUATION BY: A61
OTHER(S) PRESENT:
LLQ GN]1VL
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 SII, - 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 - Nonplastic 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
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PEW7M!l
Davie County Health DepartmentEnvironmental Health Section
P.O. Box 848 1997
Mocksville, NC 27028
(704) 634-8760 ENVIRONMENTAL HEAL
DAVIE COUNTY
****E*APORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Ney-r% ��./.2 T Contact Person &:4
b 4 i/ c 1 /S. / U 11 �� �^ Dme ne
.Mailing Address Ph,
i
City/State/Zip �� �. - e Business Phone �W�
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [ ] Site valuation
City/State/Zip
[ ] Improvement Permit & ATC oth
4. System to Serve: House [ ] Mobile Home [ ] Business [ ] Industry
5. If Residence: # People # Bedrooms # Bathrooms
( rVZshing Machine [
[ ] Other
[ 'Dishwasher [-rdarbage Disposal
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 [ ] Community
8. Do you anticipate additions of expansions of the facility this system is intended to serve? [ ] Yes [,1vo
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
/// L SUBMITTED WITH THIS APPLICATION.
Property Dimensions: ! (D d a J WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #X789 - - Azs
Property Address: Road Name/ &i ,2r� . %� T 92
City/zip f� dyWez .w- () y 20.
If in Subdi ' ion provide 1/formation, as follows:
Name:
Section: Z Lt #: ;
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
DATE -7—,12 —1e7z7—
Revised DCHD (06-96)
ETA
the site suitability.
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