148 Shady Grove Lane Lot 4AUTHORIZATION NO: Q 6 6 3 DAVIE COUNTY HEALTH DEPARTMENT
? ' Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848 /
Name J ��A /amu �/I Mocksville, NC 27028 Subdivision Name: �11� H'G► 0✓e
Phone #: 704-634-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR ;
WASTEWATER Tax Office PIN:#. 70 I- - Baav
SYSTEM CONSTRUCTION
Road Name• 0. r'R.a
6A ` (o
**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 FormlAuthorization 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)
- n
***NOTICE*** THIS IS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/.f/% IS VALID FOR A PERIOD OF FIVE YEARS
"ENVIRONMETAL HEALTH SPECIALIST., DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee s p c"`: /I
NameIIAAu��',; Subdivision Name: _�N0.�1(� ('Tro✓Q-
Directlons to property: fi'fr % r>� �� I✓.fC� Section: Lot:
IMPROVEMENT '�:
PERMITTax Office PIN:#'%p I -(��tl = %ami p
Road Name• .0 ra. t• Y1 Li ?
**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
constructionlmstallation 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:
J,/) P IJP PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALISTDATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE.
INSTALLING THE SYSTEM. .
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS 4.-5 # OCCUPANTS GARBAGE DISPOSAL Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE - # PEOPLE # PEOPLEISHIFT # SEATS _ INDUSTRIAL WASTE: Yes or No
LOT SIZBZ 1Z-t//TYPE WATER SUPPLY
•-A DESIGN WASTEWATER FLOW (GPD) '/ /, �NEW SITE � REPAIRSITE
SYSTEM SPECIFICATIONS: TANK SIZE /&'GD GAL. PUMPTANK GAL. TRENCH WIDTH ..PC �" ROCK DEPTH /-,)"LINEAR . FT. J'Lt�J
.. OTHER
REQUIRED SITE MODIFICATIONS/cONDTIIONS:: -
"*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: E
7s
. ..... . ...... _j
AUTHORIZATION N0.'. D G OPERATION PERMIT BY: / ` �"CY/rD - DATE:. 7 ��
*"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 NOWAY BE TAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -
DCHD 05/96 (Revised)
I 'w
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE
Davie County Health Department vv LS
9 t Environmental Health Section
Call P. 0. Box 848 FEB —3 1
`�Q Mocksville, NC 27028
1 (704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed t O)he t ra Contact Person Joke FU 1 K
Mailing Address ')nq WaAtr Home Phone 16q-qli "o%s9
City/State/Zip Ht%4er5y'i)1e. NC. 2.$079 Business Phone qlQ-'t'0 -
(apdt� 3 pM
2.
Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3.
Application For:
Site Evaluation Improvement Permit & ATC
❑ Both
4.
System to Serve:
Jd House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5.
If Residence:
Li
# People # Bedrooms �J #
Bathrooms J1a
Dishwasher
gGarbage 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: 7 r County/City ❑ Well
❑ Community
8.
Do you anticipate
additions or expansions of the facility this system is intended to serve?
❑ Yes ONo
If yes, what type?
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: I y O X a 10
Tax Office PIN: # S7
Property Address: Road Name S L r' D i i Gro t' L r, n .9--
city/zip A dya n c 2
If in Subdivision c provide information, as follows:
Name: S6ttAv GroVe.
Section: Lot #:
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
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 7" k' k ANA v k to conduct all testing procedures
as necessary to determine the site suitability.
DATE �6 _�i Y997 SIGNATURE
Revised DCHD (06-96)
' DAVIE COUNTY HEALTH DEPARTMENT
J Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME =//6' DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE �Y%C
SUBDIVISION '� !O /P ROAD NAME
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4 5 6 7
Landscape position .
LZl
Slope %
HORIZON I DEPTH
Texture group
Consistence
-
Structure
Mineralogy
HORIZON II DEPTH
*e- +
Texture group
Consistence
Structure
/G /
Mineralogy
HORIZON HI 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: �� EVALUATION BY:/u? 4/Z
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
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI : Extremely firm
et
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structur
SC -Single grain . M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
MineraloEy
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
Dcaot01-90: