164 Oakland Avenue Lot 33AUTHORIZATION NO: 0748 DAVIE COUNTY HEALTH DEPARTMENT
+ Environmental Health Section PROPERTY INFORMATION
Permtte4,s ;► .. P.O. Box 848 �.
Name: Mocksville,_NC..27028 Subdivision Name: t,{ ti� �- `!
Phone #: 704-634-8760
Directions to property,.? Section: ,er Lot:_
AUTHORIZATION FOR
WASTEWATER y 69
Tax Office PIN:# `�
SYSTEM CONSTRUCTION
Road Name: G�i°i� AI� Wt.2ip: CqU� r�
**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)
***N01ICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
n VALiLrVKArr1uv11vr rivr, irrvna.
`ENVIRONMENTAL HEAL II SPECIALIST DATE
DAME .COUNY HEALTH DEPARTMENT ,
MPROVEMENT AND 'OPERATION PERMITS PROPERTY INFORMATION
Trot ,
am
Subdivision Name:
w Dirt AionetA r 7 ' , . !' ;Section: .. Lot:
IMPROVEMENT
PERMIT Tax Office PIN:* - -'
Road Name: M 41 4V *aA?
_ *"NOTE*.* This Iftrovement Permit DOES NOT, autho ize the c oAstruction 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
constnictionfimstallation 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 Treatment and Disposal Systems)
- = ***NOTICE*'!* THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
`ENVIRONMENTAL HEALTH SPECIALIST DATE ISS SYSTEM CONTRACTOR MUST SEE Tins PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHwr # SEATS INDUSTRIAL WASTE: Yes or No
LOT'S. TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) -Sb NEW SITE � REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE
GAL. PUMP TANKGAL. TRENCH WIDTH .J ` / ROCK DEPTH LWEAR FT.d a
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 (704) 634-8760.
DCHD 05/96 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department cc
Environmental Health Section j 1
P.O. Box 848 i
J
�DQ I �� "V Mocksville, NC 27028 ' MAR - 7 j99T
pll
(704) 634-8760
****IMPORTANT****
mm
THIS APPLICATION CANNOT BE PROCESSED UI SS
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Contact Person S b >'Y-, 'e r'' /
Mailing Address �% Home P7ta
hone { �— 2
City/State/Zip Al"VK:yiI) ,-- AJ. • L Business Phonesy-
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: 1-1-11s—ite Evaluation
City/State/Zip
[ ] Improvement Permit & ATC I [ ] Both
4. System to Serve: [V*Jouse [ ] Mobile Home [ ] Business [ ] Industry
5. If Residence: # People # Bedrooms_ # Bathrooms_
[0—'Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
[ ]Other
[ ishwasher [ ] Garbage Disposal
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: [ ounty/City [ ] Well [ ] Community
i
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [tiro
If yes, what type?
EITHER A PLAT OR SITE PLAN
�1U
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***XA MAT OF THE PROPERTY MUST BE
SUBMITTED WITH TjH)GS APPLICATION.
Property Dimensions: ? DO ?/Ub ; WRITE DIRECTIONS (from ocksville) TO PROPERTY:
Tax Office PIN: # 41718 _ Y/7 -Q c—F
Property Address: Road Name 6 GAI"t' �'n&Ie—�
City/Zip
If in Subdivi(s�ion pr/ovide information, as follows:
Name: V � L�A-gtd4 S
Section: v Lot #:
� I
This is to certify that the information provided is correct to the best of my
subject to suspension or revocation, if the site plans or intended use change, or if the
changed. I, also, understand that I am responsible for all charges incurred from this
R--preative of the Davie County Health Department to enter upon above desc
by M
sen r
to gonduct all testing procedures
DATE 2? 117=q ? SIGNATURE �6'
Revised DCHD (06-96)
THIS AREA MAY 13E USED FOR L)RAIVINC YOUR SITE PLAN:
05
I understand that any permit(s) issued hereafter are
ormation submitted in this application is falsified or
plication. I, hereby, give consent to the Authorized
)ed property located ini Davie County and owned
necessary to determined the site suitability.
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DAVIE COUNTY HEALTH DEPARTMENT
/f
' Environmental Health Section SECTION LOT :�'.
Soil/Site Evaluation TT
APPLICANT'S NAMED TE EVALUATED
PROPOSED FACILITY PROPERTY SIZE -,/:2 4 c-
SUBDIVISION /i� ��`Jf ROAD NAME�/C
Water Supply:
On -Site Well
Community
Landscape position
Public
Evaluation By:
Auger Boring
Pit I
Cut
FACTORS
1
2 3 1 4 5 1 6 7
Landscape position
Sloe %
I
HORIZON I DEPTH
Texture group
Consistence
I
Structure
I
Mineralogy1
HORIZON II DEPTH
f
p I
Texture groupG
I
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
o�
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
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 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
DCHD (01-90)
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