386 Michaels Roadrho
NO: 0871 DAME COUNTY HEALTH DEPARTMENT '
Environmental Health Section " PROPERTY INFORMATION
P,e� ee sr P.O. Boz 848
Na�tz Qr?l i 114'4N
(�� Mocksville, NC 27028 Subdivision Name:
Phone #: 704-634-8760: W "
Direr ions to property: 2M- G a /L Section: Lot: p
-'.AUTHORIZATION FOR
.. WAS'T'EWATER Tax Office PIN:#
SYSTEM CONSTRUCTION . _
Road Name:jiltel".-Rd7ip:.2 %)OV
**NOTE* *,This Authorization for Wastewater System Constriction 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)
// ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR APERIOD ,OFFIVE YEARS. '
ENVIRONMENTAL HEALTH SPECIALIST" ;:. DATE ISSUED
/r.: f"+`ss,Yi-•':j'f''YR"`HK<i'nVT,.I'*:'LYIF;l'n'n(n,l'^t:1Nil it/Tn-:-i ;a ,a,:u••;w�.'t...�ti. 3Y ....yi1.',+ :..y1..... --L. r....n.ny�'V/�Vre:`.
DAVIE COUNTY HEALTH DEPARTMENT , y
IMPROVEMENT AND OPERATION PERMITS PROPERTY'1NFORMATION
NatYre `� oC+EY a." ��l AM Subdivision Name -
to "W"dlQGLf. r� Section: �Lot:P
IMPROVEMENT �J��� �t �)
PERMIT Tax Office PIN:#.7tt /'(-+-.�- 0 d
Road Name 711 IA a CA-- ��•Zip: A / 110f A
**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 Departm��prior to the
construction/installation of a system or the issuance of a building permit.
(m 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
y'` l+, . ✓.;, y r; Gr` y ; f%:"< l✓:' , PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED - SYSTEM CONTRACTOR MUST SEE1111S PERMIT BEFORE
INSTALLING TIRE SYSTEM.
RESIDENTIAL. SPECIFICATION: BUILDING TYPE V_Z—,4 # BEDROOMS \ T' # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
. - . COMMERCIAL SPECIFICATION: FACILITY TYPE,�J ,, # PEOPLE # PEOPLE/SHIFT �,7 # SEATS _ INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY C:!/r�/DESIGN WASTEWATER FLOW (GPD) .,VQ v NEW SITE 4_-l REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 6t7 GAL. PUMP TANK " GAL: TRENCH WIDTH , o' - ROCK DEPTH 22 LINEAR FT.,f o b
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: -
**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) 6348760. -
OPERATION PERMIT - . _ - • , 1 �' L,, _ n� _
' - SYSTEM INSTALLED BY:
S
loot, o>
Loo �
AUTHORIZATION NO. ` OPERATION PERMIT BY: 666 DATE: Z
"THE ISSUANCE OFTHIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 71 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.
05/96 (Revised) - - - - -
I
1.
2.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(704)634-8760
.****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED U =
ALL THE REQUIRED INFORMATION IS PROVIDED.
a�
-
Name to be Billed �P t�I I M2Yl Contact Person� *;&Cu�'YSG.7q-g9P`
�7
Mailing Address 120Rny �3s Home Phone p?,q- Q%� /
City/State/Zip . 0Q Q O J i Business Phone "'A a - a ss
Name on Permit/ATC if Different than Above
Mailing Address 4 A Cii /state/zip MVA
3. Application For: LAS Site Evaluation U Improvement Permit & ATC Both
4. System to Serve: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People - # Bedrooms 3 # Bathrooms �'
❑ Dishwasher ❑ Garbage Disposal L9 Washing Machine ❑ Basement/Plumbing
6. If Business/Other: Specify type 01A # People
# Commodes # Showers # Urinals
If Foodservice: # Seats Estimated Water Usage (galloons per day) _
7. Type of water supply: ElCounty/City IN Well
❑ Basement/No Plumbing
# Sinks
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
INFO�RoM�A'TION P
n
--V)
Property Dimensio .$ It J E O re". -M L&:A k / LAO -re- -ncl 71
It-I'Barg 11
Tax Office PIN: # �� -
1
Property Address: Road Name m .i r hod ^S (Cd . 1
city/zip_LYS^ �stlla,J.1'dar)o0
If in Subdivision provide information, as fol ows
Name:
-r AG'P� ✓�B 1
Section: Lot #: 1
1
❑ Community
❑ Yes yc tv o
OF THE PROPERTY MUST BE
TED WITH THIS APPLICATION.
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
as necessary to determine the site suitability.
DATE 1 ASIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
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Scale: l"=•'••••••"• May13,19973:58PM
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME l
PROPOSED FACILITY
SUBDIVISION
SECTION LOT_
DATEEVALUATED
PROPERTY SIZE
ROADNAME �IZi�Cg %l
Water Supply:
On -Site Well z/
Community
Public
Evaluation By:
Auger Boring
. Pit
Cut
HORIZON I DEPTH
Texture group
FACTORS
1
2 3 4 5 6 7
Landscape position
C
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
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
LONG-TERM ACCEPTANCE RATE
,
SITE CLASSIFICATION: EVALUATION BY:G'/
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 loamL - Loam SI - Silt
SICL - Silty clay loam SII. - 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
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)
LIAR - Long-term acceptance rate - gal/day/ft2
DCHD (01-90)