145 Rabbit Farm Trail Lot 3Permittee'seh
�5 DAYIE COUNTY HEALTH DEPARTMENT
Name: �� , r A o �1'�%r Jam' Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 16,4
,L
Directions to property: 7 F Mocksville, NC 27028 Subdivision Name: t
�t /% / /� Phone #: 336-751-8760
e— / /C �/- Section: Lot:
r tj �01 AUTHORIZATION FOR
WASTEWATER
R dry �r i � � °` , SYSTEM CONS STI Tax Office I%.N::# - -
AUTHORIZATION NO: O O Z 9 9 2 4 Y; "°' K ms'' ! e/�• Road N �" Tr zipp'700&
**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 FomVAuthorization 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
IS VALID FOR A PERIOD OF FIVE YEARS.
AL HEALTH SPECIALIST DATE ISSUED
Permittee's DAVIE COUNTY HEALTH DEPARTMENT
Name: i/ r Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 '"—
Directions to property: (� y I la Mocksville, NC 27028 Subdivision Name:" C%
/) Phone #: 336-751-8760
�rJ/Y1 ��- �z�.." (l Section: Lot: 3
rlQ W�� G v► AUTHORIZATION FOR
l o y y/ WASTEWATER
r t nr,•I r•y � � Tax Office 1N:#
—` SYSTEM CONS �Jtt�}}CTI-g9N
®®2�Nr� Y ,,t461'Yt,pl �y5 G��fG�n�7r �7t��
AUTHORIZATION NO: A Road Name: Zip.
*.*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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�,r'�✓ /. f` ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
?NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE 5 T # BEDROOMS 3 # BATHS __3— # OCCUPANTS _Q, GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
t C- le>
LOT SIZE TYPE WATER SUPPLY 14/C//DESIGN WASTEWATER FLOW (GPD) 36 ep NEW SITE REPAIR SITE
r
SYSTEM SPECIFICATIONS: TANK SIZE / GAL. PUMP TANK40� GAL. TRENCH WIDTH ROCK DEPTH -J�-a— LINEAR FT. —
As stated in 15A NCAC 18A.1969(5) I
OTHER accepted Systems may also be used �
REQUIRED SITE MODIFICATIONS/CONDITIONS:
PERMIT LAYOUT
%J / _ ��je FN-
CL
kA✓oh'
70 • t <<
70 w
y � ins
rs b b .'t' ice' C)6.ewnT r .
L.•I'eiV a ::"'� cL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
PERMIT
AUTHORIZATION NO.
OPERATION PERMIT BY:
SYSTEM INSTALLED BY:
DATE:
**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 02/02 (Revised)
Permittee's /� j DAVIE COUNTY HEALTH DEPARTMENT
Name: - (I /'%��;� "� Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 1
Directions to property: �� � l Mocksville, NC 27028 Subdivision Name:` r ` t� `� + 1 ' {'f
}" Phone #: 336-751-8760-'
Section: 7 Lot:
r < f AUTHORIZATION FOR
(( '� , -/ " fir a 114 % f' ( rG i WASTEWATER Tax Office.PIN:#
Lo �1[ SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002/1 ` Road
am�(1e:r!l%�
Zip:'
**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 Pennits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
.y t,
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
r
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS 3— # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
_ y z!;c %--�S
LOT SIZE TYPE WATER SUPPLY ��//DESIGN WASTEWATER FLOW (GPD) 3, r � NEW SITE REPAIR SITE
/GQ //
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH _14L LINEAR FT.
Az slE:cd in 15A NCA.0 1,13,1.1E£3;5) I
OTHER LYccp �d f1-,y3tCMS may @!110 bo uSC'Cl + 1
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPR
VEME
T PERMIT LAYOUT I
tV`�
66 1V �
71" t
µ'ms , —i -FOR -FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
TION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. 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 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 02/02 (Revised)
fi Permittee's I DAVIE COUNTY HEALTH DEPARTMENT
Name. �� f' l / / ' e" r J Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: �r ` L A) Mocksville, NC 27028 Subdivision Name:'`
f ) Phone #: 336-751-8760
Section: 7 Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
p99? f - -
AUTHORIZATION NO: �i Road Name Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office wherr applying for Building Permits.
(In compliance with Article I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
el
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS --� # BATHS —i— # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
y
LOT SIZE TYPE WATER SUPPLY I" VAI/DESIGN WASTEWATER FLOW (GPD) 3c//L�) NEW SITE REPAIR SITE //
SYSTEM SPECIFICATIONS: TANK SIZE /L_GAL. PUMP TANK GAL. TRENCH WIDTH 3l r , 'ROCK DEPTH LINEAR FT.�
,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
PERMIT LAYOUT
r
71,
\ f A"- _L rl c
rt �n
—!.–iFORrFINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
PERMIT
AUTHORIZATION NO
OPERATION PERMIT BY:
SYSTEM INSTALLED BY:
DATE:
**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 02/02 (Revised)
�'• DAVIEOUNTY HEALTH DEPARTMENT
54";
Environmental' Environmental`Health Section PROPERTY INFORMATION
-, %� P.O: Box 848 _}
Directions to Property "' �1'� Mocksville NC 27028 Subdivision Name
CC. y <<y '� e'l, : �~ .<} ,: j r 5 iQ
Phone 336-751-8760 .
�,
1 Section: Lot:.
�� f �.., y,'a (�- tt e {• $ �+ ca AUTHORIZATION FOR
WASTEWATER
G
Tay Office PIN:# SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: Road Name: Zi
**NOTE** This:.Authorization for Wastewater System Conswction 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'I I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
1
**NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST j! DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS . # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
Art 1 u
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOP�jyad I,�g
)L # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
ujp
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) I Qy NEW SITE / REPAIR SITE
5Y977:M SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3 G ROCK DEPTH LINEAR FT. 1
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
FOR FINAL INSPECTION OF THIS SYSTEM.PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION.. TELEPHONE # IS (336) 751-8760.
**TIS ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I OF G S CHAPTER I30A; SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHA LL,IN NO WAY BETAKEN AS A
GUARANTEE THAT MSYSTEM; WII I FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DM r>2ffl2 (:+peal 1 t
IMPROVEMENT PERMIT LAYQI rr
t
�(
�� ;
r fID
FOR FINAL INSPECTION OF THIS SYSTEM.PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION.. TELEPHONE # IS (336) 751-8760.
**TIS ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I OF G S CHAPTER I30A; SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHA LL,IN NO WAY BETAKEN AS A
GUARANTEE THAT MSYSTEM; WII I FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DM r>2ffl2 (:+peal 1 t
',o'Iie m tte_e's DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:1 %
Phone #: 336-751-8760 -�
!I' Section: Lot: . .
��
AUTHORIZATION AEWATF.R OR �j `� (�
a r � 7
�3 �j q SYSTEM CONSTRUCTION Ta� Office PIN:#
AUTHORIZATION NO: A Road Name: Zip:-
' **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen -nits. 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*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL• SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
/6 ef(O i
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
,- tF 1
LOT SIZE �� � � TYPE WATER SUPPLY U'I { DESIGN WASTEWATER FLOW (GPD) � Vy NEW SITE � REPAIR SITE
1 oae III I
SYSTEM SPECIFICATIONS: TANK SIZE -'/GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH "' LINEAR FT.' '� t
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYQLLT--
e
Y
V
V
IS
I
777
L,J
S
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
AUTHORIZATION NO.
i
OPERATION PERMIT BY:
SYSTEM INSTALLED BY:
DATE:
**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.
I)CIID 07J02 (Revised)V. it &0' /
" �-
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
�046'i" 3.ea.% N4XVtS'0h �)OL'9 k
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit
PROPERTY INFORMATION
k'a 6 61 t -F&f M 5L,10-
Seel_ - 3 o7( 3
�$ 2a- 6 A — 9 v -6
-�—
l 1 E F Q �0 b �rt f -area I/ I
�7d0�
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Slope %
HORIZON I DEPTH
Texture groupG
Consistence
Structure
Mineralogy
HORIZON H DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
AAt
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
.a7j
SITE CLASSIFICATION: P-5
h�
LONG-TERM ACCEPTANCE RATE: � ' 0a 7✓
REMARKS:
LEGEND
EVALUATION BY: AJ /(/ J t O Al 5
OTHER(S) PRESENT:
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
u,
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Ykt
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
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 DCHD 05105 (Revised)
• "'
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\,
�'
// . /ate
AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT ,8, , 0
NamePermit-tee's /1'
(�
'Environmental Health Section
P.O. Box
PROPERTY INFORMATION
Name: j7 lr(i1fe
2
Mocksville, NC 27028
Subdivision Name:
�j 7(f''�/�Il
Directions to property: (
Phone # 336-751-8760
--}
Section: �.-- t1X "? Lot:
o. -J 141 , Jr
AUTHORIZATION FOR
WASTEWATER
Tax Office PIN:#
f �7/
SYSTEM CONSTRUCTION
Road Name: 27
**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 f'of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
VIRONMENTf1L HEALTH WCIALIST DA'
DAVIE C OUNTY HEALTH DEPARTMENT �(
" IMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION V U
r
Permiltet
Name: Subdivision Name: -ol-
11
9 i .d , r : Lot:
Directions to property:L 'c i Section: e.
IMPROVEMENT
6-7
Tax 7.1VPEMf fid ejJ
Road Name: jUa►1��tZip:1�%�D
**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',l l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r
.-^ --; ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH 75IALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE tj�[)SC# BEDROOMS 3 # BATHS 2.15' # OCCUPANTS Z GARBAGE DISPOSALS or No
COMMERCIAL SPECIFICATION:
IFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT�/ # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE 5.0 / ��r ��TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) � NEW SITE � REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE I t-J0VGAL. PUMP TANK GAL. TRENCH WIDTH' ROCK DEPTH Z 1 LINEARFT.
OTHER F 17� �iT � 1 �j1� � I [ "� X
REQUIRED SITEMODIFICATIONS/CONDITIONS: Pi-- /c) Crr tA)EA-&,, gc!:�Ej /C
IMPROVEMENT PERMIT LAYOUT
lUt3•_`=
00
llf�4'�
&115�
ry 2oa !�
"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.
I OPERATION PERMIT
AUTHORIZATION NO. 1
"THE ISSUANCE OF THIS OPE
11ITHARTICLE110FG.S.CHA.......--
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
SYSTEM INSTALLED BY:
DM 051% (Revised)
DATE:
NSTALLED IN COMPLIANCE
LL IN NO WAY BE TAKEN AS A
� a
r
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
***IMPORTANT*** THIS APPLICATION CUMOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed ' /— —
Mailing Address /1 (6 8" a
fe' I j
ep -Intact Person( / , , & i0/
Home Phone 9( 8- /-/7-) 1
City/State/ZIP / -r p v q'Ur- Business Phone 19-13- g '7 /d
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: ❑ Site Evaluation
City/State/Zip
D-1='�P-rovement Permit/ATC ❑ Both
4. system to service: ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People P— # Bedrooms —3 # Bathrooms v2 -
Q Dishwasher Garbage Disposal U -lashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Nater Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 330
Tax Office PIN: #
Property Address: Road Name
City/Zip
If in a Subdivisionprovide information, as follows:
Name: Ro b b,1
Section:G&t�3 Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
ns�. �— W4 WW
•
A
I
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 Coun Health Depa ent
to enter upon above described property located in Davie County and owned by Z.r;.✓G ��, •.eZi�c
to conduct all testing procedures as necessary to determine the site Nuabifity-,
DATE ? -1q -5F
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
Revised DCHD (07/98)
Account No. 9-11�
Invoice No. �'7�d
` . APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE
Davie County Health Department
Environmental Health Section
i;
P.O. Box 848 AUG -7 1997 .
Mocksville, NC 27028
M (704) 634-8760 E1JV1R0�11.��'T;.t 117"
1 01Vi� (.X191;;
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed `9 6 'e
Mailing Address b t s
City/State/Zip
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: [-r Site aluation
CoIda,e,4lj�L.
Contact Person (2;eyu
Home Phone 3 ��
Business Phone
City/State/Zip
[ ] Improvement Permit & ATC [ ] Both
4. System to Serve: [ ouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People_ # Bedrooms—,-? - # Bathrooms [ ishwasher [ +< bage Disposal
[ashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
—
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Wate Usage (gallons per day)
7. Type of water supply: [ ] County/City [ ell [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes lM o
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT **,tA)NMT OF THE PROPERTY MUST BE
S-, V 7 ax4-(,o SUBMITTED WITH IDIS APPLICATION.
Property Dimensions: 1 .335 X 71a 3 3 5.Y %Z WRITE DIRECTIONS (frorr Mocksville) TO PROPERTY:
Tax Office PIN: # 70 F—?tz
Property Address: Road Named 6tq k� TCL
City/Zip 1; `% 00(oP�K�-d
If in Subdivision provide information, as follows: —
II
Name: Gl bf 3L 4 eo -
Section: Lot #: 3 ;
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
Represen ative 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.
D E �S LI rI SIGNATURE .y /� -7
Revised DCHD (06-96) �✓l 10-I /
THIS AREA MAY 13E USED FOR DRAIVINQ YOUR SITE PLAN:
1 SEAL iINJa W. GIIINSKI
. 1 1540 c:l w, co— c"
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION 1 i 1- LOT -3
Soil/Site Evaluation
APPLICANT'S NAME �i \C DATE EVALUATED b Q> ' J
PROPOSED FACILITY��C.S ' PROPERTY SIZE_ Q� ' 4-1 ��
SUBDIVISION ��� �`� ROAD NAME
Water Supply:
Evaluation By:(ZA L
On -Site Well Community
Auger Boring ✓ Pit
altnry
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
O- 1W
OSO
-
HORIZON I DEPTH
411
6 If
Texture group
C-1—
L.
Consistence
Structure
Mineralogy
HORIZON II DEPTH
4zt'
Texture group
Consistence
-�
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
s5
RESTRICTIVE HORIZON
--
SAPROLITE
CLASSIFICATION
.S -
s
LONG-TERM ACCEPTANCE RATE
C ♦ J
SITE CLASSIFICATION:•S EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS: ` _ AlJ
DCHD (O1-90)
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
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 - 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/ft2
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■■
ME
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Davie Coun Health Department
� F
and Home Health Agency
EnvironmentafHeafth Section
P.O. Box 848 / 210 HOSPITAL STREET
COURIER #09-4-06
MOCKSVILLE, N.C. 27028
PHONE: (704) 634-8760
August 19, 1997
Kathy Green
166 Adams Ct.
Winston-Salem, KC 27127
j
Re: Site Evaluation
Rabbit Farm III/Lot 3
Dear Client:
As requested,• a representative from this office visited the
aforementioned site on August 13, 1997. Based upon the information
provided on the application for site'evaluation and after the evaluation"
was completed, the site was found to -be provisionally suitable for the
installation of an on-site sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely, j
Robert B. Hall, Jr., R. S. "
Environmental Health Specialist
RH/wd
Enclosure(s)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION � LOT 3
Soil/Site Evaluation
APPLICANT'S NAME V -4-r f"t &ZagV DATE EVALUATED
PROPOSED FACILITY D � PROPERTY SIZE` n ,�S • ? /4�
SUBDIVISION A2rl-/ ROAD NAME 'u-I�F�I% &e,
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS 1
2 3 4 5 6 7
Landscape position t- Or
L
Slope %
Z v
HORIZON I DEPTH 19-90
0-50
Texture group L
G
Consistence 5
'
Structure
$
Mineralogy,
HORIZON II DEPTH
Texture group
Consistence
i S
Structure
Mineralogy'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
--
RESTRICTIVE HORIZON —
SAPROLITE --
—
CLASSIFICATION I PS
S
LONG-TERM ACCEPTANCE RATE I Q, f
en
SITE CLASSIFICATION: CS
LONG-TERM ACCEPTANCE RATE: O -
REMARKS: _0 C -LAY . &yo 0 5W.
LEGEND
DCHD (01-90)
Landscape Position
EVALUATION BY:
OTHER(S) PRESENT:
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
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 - 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/ft2
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