347 Michaels Road Lot 26v-:• :1,111t' -.,."Y'.r.,M ..k -x. :t'r ,ti '..�4 ,. ..s .'_'iy,••r'"' r"` .,`}-
�ii?T OpIZATIwIN NO:
1561 DAVIE COUNTY HEALTH DEPARTMENT i O
Environmental Health Section PROPERTY INFORMATION
Permittee's• P.O. Box 848
Name: r7''' Mocksville, NC 27028 Subdivision Name:�•
/ / Phone # 336-751-8760
Directions to property:/> i f ,�: % Section: Lot:
AUTHORIZATION FOR
WASTEWATER ! .� .�
Tax Office PIN:#
SYSTEM CONSTRUCTION -^
Road Nam
e:
**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)
f _, ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
j� IS VALID,FOR A PERIOD OF FIVE YEARS.
it
ENVIRONMENTAL HEALTHYSPECIALIST DATE ISSUED
�,Q••w�- 7 �ZG Y - _r'T"_'. Yn Tr+.+ �r•-.vr-�w.Ttyr,�,i..,i�yV,. ��+v. c,'.�•'�,,-.�^.f. -,-� •r•• -. �"+N_
ev 4f;
�t DAVIE,• OUNT' HEALTH DEPARTMENT
I11PR0 VEMENT AND OPERATION PERMITS ..PROPERTY. INFORMATION.
Name a ; l ' ' ` ''Subdivision Name._rf E..'•
ITlrech6n toPpettyio '. �' Section Lot:
- _
- � . ` IlKPROVIINFNT �
+ i PkRMtf Tax (5fhce PIN:# -
K Rbad Name:
**NOTE*; This Improvement Perinit:DOES NOT authorize tiie'c6nsttugtion or installat on of a sepgc'tank system or any wastewater systertL. An
AUTH6kZATION FOR' WASTEWATER SYSTEM .CONSTRUCTION must be: obtained um this Department-prior to the
constnwtion/msWiAtion of a system or the *ts moe of a building pe*t
On.compha Ice with Article,l l' of G S _Chapter I30A; Wastewater Systems, Section 1900 Sewage Treatment and Disposal Systems)
F
#**NOTICE*"• TIQS PERNIIT IS SUBJECT TO REVOCATION IF SrM
PLANS OR THE E14TF DED USE CHANGE. YOUR WASTEWATER.
FNC{IRONMENTAL HEALSPECIALIST = DATE:ISSUED' CONTRACTOR MUST SEE TliLS: tER11�T a>01
y a INSTALLING TH>•; SYSTEIVL
RESIOENTLAL SPECIFICATION BUILDING TYPE ' � /f # BEDROOMS �, # BATHS ' _ # OCCUPANTS ' ' GARBAGE, DISPOSAL: Yes or No
`COMMERCIAL SPECIFICATION:. FACIIM TYPE #PEOPLE # PEOPLE/SHIFT - #SEATS WDUSTRLAL WASTE: Yes or No'
LZI , DESIGN WASTEWATER FLOW,(GPD) Tig _
. LOT SIZE TYPE WATER SUPPLY � a 'NEW SITE REPAIR SITE ' •
SYSTE�N.:SPECIF7CATIONS: TANK.SLZF�GAL PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH /� LINEAR FT.=��
OTHER
REQUIRED SITE MODIFICATIONS/CONDMONS
"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 (336)751-8760.
ua-nu uwyo �rcov�sw� • �t -.
<w w APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMILl'w
Davie County Health DepartmentDEnvironmental Health Section
P. O. Box 848 7--jim
Mocksville, NC 27028
(704) 634-8760 l_tt�fMI
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE
�'/
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �0 �r �"'I �' Contact Person Pw'�-
Mailing Address 8W Do Home Phone �0 �-/Y/
Pd
City/State/Zip Wow"Me& 11`C- a701 � Business Phone X11-2-551
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: ❑ Site Evaluation
4. System to Serve:
5. If Residence:
a4shwasher
6. If Business/Other:
# Commodes _
If Foodservice:
❑ House
# People
❑ Garbage Disposal
Specify type
7. Type of water supply:
❑ Mobile Home
# Showers
# Seats
CII/County/City
_Ci/ty/State/Zip
.
Improvement Permit & ATC ❑ Both
❑ Business ❑ Industry ❑ Other
# Bedrooms 3 # Bathrooms
Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes DINO
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: /001y 2 0D 1 WRITE DIRECTIONS (from
!�1 Mocksville) TO PROPERTY:
Tax Office PIN: # � 7 7 p - � - �'�
n� c c h a&,(�(. � o l� s 46Property Address: Road Name / / 1 kd
M ocks V I �,
City/Zip 1 'A); n 0
1
If in Subdivisions provide informations, as follows:
Name:
1
1
Section: Lot #: 1
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 consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by to conduct all testing procedures
as necessary to determine
the site suitability.
DATE --7—I `f'-qO SIGNATURE
Revised DCHD (06-96)
,htv, //
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMI
Davie County Health Department
t Environmental Health Section JUL 2 1 1995
P. O. Box 665
!!!! I Mocksville, NC 27028
1. Application/Permit Requested By r ort 'D 'a✓_i19 6.)r t j4 CZi w on
Mailing Address /70
� y / Home Phone
Business Phone '�-k 7 s2 `✓s
2. Name on Permit if Different than Above
3. Application for: �General Evaluation ❑ Septic Tank Installation Permit
9-
4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision ""-`-"W �T 4' 14),61C Section _� Lot #
A
7.
8.
9.
17 ❑ Basement/Plumbing
No. of People
No. of Bedrooms
No. of Bathrooms
-
Dwelling Dimensions f loo
If business, industry, place of public assembly, other: Specify type _
No. of People Served
No. of Commodes
No. of Lavatories
/Bdv 5�r-/-
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures _
Type of water supply: ublic ❑ Private
Property Dimensions T� O Fit- X,, Sewage Disposal Contractor _
Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑
If yes, what type?
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ .Garbage Disposal
Yes "o
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
b �f�
F
This is to certify that the information provided is correct to the best of my knowledge,
incurred fro fthi� plication. �
DATE
I understand I am responsible for all charges
SIGNATURE ;6'
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representativ of the De�wwe Co my Health Department to enter upon above described
property located in Davie County and owned by %u t ogpnf >eey;ie-,, /111E.
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
Ay S
DATE
DCHD (1193)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
/ Soil/Site Evaluation
NAME �f�' DATE EVALUATED �1
ADDRESS PROPERTY SIZE Za(2I.36SD
PROPOSED FACIILTY �, �'t' LOCATION OF SITE _45� � ' _/
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope % •L
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
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 S
LONG-TERM ACCEPTANCE RATE
PIV
SITE CLASSIFICATION: �� EVALUATED BY: ,A&
LONG-TERM ACCEPTANCE RATE: i 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 :lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V ----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
3C --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(01-901
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