175 Dublin Road Lot 6V�. 1
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
-
wy Imc Subdivision Name: 4
y Directions to property: Section: Lot: _
�- IMPROVEMENT
PERMIT Tax Office PIN:# •�- =;
Road NameAf Uhla . Zip:. �Pe
**NOTE** Ibis 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 Treabnent and Disposal Systems) .
1 ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
v i f' Yi". f :.'C%� /J *."`✓i PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER .
ENVIRONMENTAL HEALTIfSPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE -
INSTALLING THE SYSTEM.
• RESIDENTIAL SPECIFICATION: BUILDING TYPE . W . # BEDROOMS ,V # BATHS # OCCUPANTS GARBAGE DISPOSAL. Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE/- # PEOPLE # PEOPLE/SHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY r n DESIGN WASTEWATER FLOW (GPD) NEW SITES REPAIR SITE - -
- SYSTEM SPECIFICATIONS: TANK SIZE GAL. 'PUMP TANK - GAL. TRENCH WIDTH ROCK DEPTH LINEAR Fr. PDO
.REQUIRED SITE MODIFICATIONS/CONDITIONS: - - - -
**CONTACT A REPRESENTATIVE OF THEDAVIE 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.
H oos s.
�1 Q
AUTHORIZATION NO. Olq Z- OPERATI N PERMIT B DATE: ' I
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE YSTEM DESCRB DOVE HAS BEEN INSTALLE IN COMPLIANCE
WITH ARTICLE.I I OF G.S. CHAPTER 130A,.SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. -
DCHD 05196 (Revised), ' - -
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department g,S' B A C✓�
Environmental Health Sectiones
P.O. Box 848 s -
Mocksville, NC 27028
(704) 634-8760 1
I
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed O Contact Person
Mailing Address , , HomePhone
City/State/Zip /LCS i!/ �'��t' /Y �_ =27,0-2- Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. 'Application For:ite Evaluation [PrImprovement Permit & ATC . [ ] Both
4. System to Serve: [ ouse [ ] Mobile Home [ ] Business [ ] Industry ( ] Other
5. If Residence: # People # Bedrooms # Bathrooms ,_ [r�shwasher [ ] Garbage Disposal
[ U.""washing Machine [ asement/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 [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ].Yes L3,Nor
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AiCOF THE PROPERTY MUST BE
//� SUBMITTED WITH APPLICATION.
Property Dimensions: 14, -re -L �T WRITE DIRECTIONS (from Ixksville) TO PROF
Tax Office PIN: # .2` -,2 r�((!L r/5 7 a �� Pe o D fs Crk W
`
Property Address: Road Name Iii, b it Ria. s eGT Lo7 ra �P �Y D H C77)a /� Ln
n�1/
city/Zip /7C]lap n6 ev X27 04 kl' 112 ob /e 1L
If in Subdivision provide information, as follows:
Name: / an wr. o ('Y'PS
,
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
Representaie�o I�h D� Hgalth Department to enter upon above described property located in Davie County and owned
by I o conduct all testing procedures as necessary to determine the site suitability.
Revised DCHD (06-96)
THIS AREA MAY $E USED FOR DRAWING YOUR SITE PLAN:
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DAVIE COUNTY HEALTH DEPARTMENT, /
Environmental Health Section(i
Soil/Site Evaluation
NAME ✓1
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED _
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public 4%
Evaluation By: Auger Boring Pity Cut
FACTORS 1 2 3 4
Landscape position
Slope b
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH + F
Texture group
Consistence r
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- 211, �/
LONG-TERM ACCEPTANCE RATE:
REMARKS:
Landscape Position
OTHER(S) PRESENT:
LEGEND
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 IC -Clay
wnalornn �c - .
Moist
VFR-Ve-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 _
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/fl2
DCH6(01-901
ek-
F • T QRI`LATION NO:� 0992-DAVIE COUNTY HEALTH DEPARTMENT t'
Environmental Health Section PROPERTY INFORMATION
Pernettee' P.O..Box 848
Name. - Mocksville, NC 27028Subdivision Name:`Z �
Phone #: 704- 6 34-8760
Directions toproperty:, Section: f Lot
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#� cr, ,',% -w
Road Name: l' )1. d. ZIp: d 0 4
**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 Fonn/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*** CONSTRUCTION
NOTICE - THIS AUTHORIZATION FOR
IS VALID FOR A PERIOD OF FIVE YEARS
ENVIRONMENTAL HEAL, CIALIST :.'.: DATE ISSUED