512 Rabbit Farm Trail Lot 11Davie County Health Department o . 0c)
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
r
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.***
NAGE �y1\ C Q� \ N DATE � !g J 11
WE
WE ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION P ` \ A R F' Q \� 1' oA
COM WS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
'" • DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**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
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of 6.5. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME ��� D. N-\ A P`` 0 PROPERTY ADDRESS DATE a -,[5-9L
LOCATION
oS
SUBDIVISION NAME A��O P `� `�^ JKLOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE 1� 4� S # BEDROOMS Ll # BATHS # OCCUPANTS _�_ GARBAGE DISPOSAL: Yes No
COMMERCIAL SPECIFICATION: FACILITY TYPE ' # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE;,Yes/No
u
LOT SIZE c_ 'TYPE WATER SUPPLY �.� �`�-. DESIGN WASTEWATER FLOW (GPD) IZ a NEW SITE ,.,REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE / Om GAL. PIMP TANK GAL. TRENCH WIDTH RFK DEPTH 12 LINEAR FT. iJ O U
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:'`.
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS:& THE INTENDED USE CHANGE.' YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
6
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IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOd 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 './A'� � �� w4 rrA kyZ
IAOOSI�,
Fac4S Z24 -v.
AUTHORIZATION NO. O l s OPERATION PERMIT BY TE
**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 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
lJ✓ ;1
1. Application/Permit Requested By
Home Phone % - � —/
Mailing Address
o R M N 0 T N
F6Y — 11996
VIVI11,01 SEWAL IIEPMI
ItI+VIE (xill°11if
Business Phone
2. Name on Permit if Different than Above �7/ ? ��114 n 1, ni
3. Application for: F3 General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: 2- ouse
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision4� J��= %,i)Iti A3 e V Section - Lot #
No. of People
No. of Bedrooms _
No. of Bathrooms _
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: ❑ Public C-Frrivate
8. Property Dimensions G' lik, Y -S Sewage Disposal Contractor
❑ Basement/Plumbing
❑ Basement/No Plumbing
D'Washing Machine
2.6ishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0-N6
If yes, what type?
❑ Community
'NOTE: Improvements Permits shall be valid Japm from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: !' �( �c� p� �Gi;t !1 ✓Za y Tax Off ice PIN: # 5 47
PROPERTY AbbIZESas follows:
/a Road Name:i-
r1 r) � � '_ ^��-- city: e KL'
SU$MIT A PLAT WITH TRIS APPLICATION.
Revisions effective October 1, 1995.
This is to certify that the information provided is correct to the
incurred from this application.
DATE
of my knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. Q, 9; 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:
II hereby give consent to the auorized representative
tative of thq D vi �Qynty FIQ IthDepartment to enter upon above described
roe located in Davie Countyand owned b 7` //
to conduct all testing procedures as necessary to determi a said site's suitability_for aground absorption sewage treatment
and disposal system. %
DATE SIGNATU E'
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �A�Q A , C �p ���� DATE EVALUATED - 1Jr ' a
ADDRESS PROPERTY SIZE ` `C.4.
PROPOSED FACIILTY LOCATION OF SITE QbO \ F1a'��`:*
Water Supply: On -Site Well Community Public
Evaluation ByC4_:� Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
S�
Slope %
0 -Sb
HORIZON I DEPTH
Texture group
L'
Consistence
_;A_
Structure
C
Mineralogy
HORIZON II DEPTH
73 L
Texture groupC
C
Consistence
Structure
k
k
fie%
Mineralogy'.
• I
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
.S
LONG-TERM ACCEPTANCE RATE
3
SITE CLASSIFICATION: �� EVALUATED BY:
LONG—TERM,pAC�CEPTANCE 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
SILL -Silty (:lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- Vory 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
NHD(01-901