3833 Hwy 64W Lot 16S✓Xa
.. „-..AUTHOR7,ZATION.No: 1 2 ` 6 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
PermAee'& , ,' . {�� ; ' � e P.O. Box 8481��
Name: .* -1 / '' F :. c_:+3d .a` . Mocksville, NC 27028 Subdivision Name _ � �. Ir (7'6 /'�
� , Phone #: 704-634-8760
Directions to property: ' ^41A,2
41A Section: Z Lot: c:
AUTHORIZATION FOR
WASTEWATER*
SYSTEM CONSTRUCTION Tax Office PIN:# �' �+ - � X
J'3 3 3 U,5 / 1 W 7 6 `1 (/j/ad Name. ' -XX j Zip: aq L
**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 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
_4.2,26DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION,,
Aft
Subdivision Name:
. ; Directions to property ! / Section:
j IMPROVENWNT - -
PERMIT Tax Office PIN:#
Ui S3 b oad Name: Zip: y y
**NOTE* This Improvement Peiinit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
3 AUTHORIZATION=.FOR WASTEWATER SYSTEM CONSTRUCTION must'be obtained from this Department prior to the
S construction/mstallati'on"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 ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
z INSTALLING THE SYSTEM. ;. s
RESIDENTIAL SPECIFICATION: BUILDING TYPE _ #BEDROOMS #BATHS _ �� #OCCUPANTS_ GARBAGE DISPOSAL: Yes or No, .
COMM—ERC/IAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT S12Z, / lI .TYPE WATER SUPPLY ` y DESIGN WASTEWATER FLOW (GPD) ,�G D NEW SITEy REPAIR SITE /
SYSTEM SPECIFICATIONS: TANK SIZE c 1 GAL. PUMP TANK GAL. TRENCH WIDTH C ROCK DEPTH LINEAR FT.,fV
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
AUTHORIZATION NO. –� OPERATION PERMIT BY: DATE: d
**THE 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 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.
DCI1605/96 (Revised) .
A:.
I
- APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
- lI1!I
FEB 161998
1. Application/Permit Requested By ri-t' IL +CJI G QI lI t-,0115 I L ul ` i 1011 v EN.F IY 10 C1 E! 11 f 1 h! --N "-
Mailing Address x�o Home�PPhhone 770 L331L- 302 3
y5y lie/ yV C ;1-7b%0 a k Business Pho
r lne —IoLI '103?j��53�
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve: )4 House
gGeneral Evaluation JV Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision 0(tkland P(Lh h+j Section Lot # �P
No. of People 7
No. of Bedrooms 3
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: A Public ❑ Private
8. Property Dimensions 100 X ADD x )00 x 60 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
Directions to Property:
to i4wq �q. VW , pubf DaVIA Rc .
wi-5 Have Foie. :5H2E 131� ouJt4er s19a
On ppp&y, 1000 fit. pCo - Q: o
Ct m w rrAcWo
❑ Basement/Plumbing
❑ Basement/No Plumbing
9 Washing Machine
3Z Dishwasher
❑ Garbage Disposal
❑ Community
L, No
PROPERTY INFOP.1,1ATION REQUIRED:
Tax Office PIN # )4-7cigruD r5o
Road Name U5 illu), j W W
Dox # (if available)
Oily ffl0&5yi I I e . njr a704)?
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incur
Z
from this application.
DATE SIGNATURE lvn 0 hslr i✓
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. X2. 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 represent,tive of the Dav6olinark
County Health Department to enter upon above described
property located in Davie County and owned by t- P TI S /'.
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and dispo$al system. 11� Z9 . n • I If
I I DATE / / SIGNATURE
DCHD (1193)
M
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
�J �v
APPLICANT'S NAME
PROPOSED FACILITY
SUBDIVISION
Water Supply: On -Site Well
Evaluation By: Auger Boring
Community
Pit
SECTION--/ LOT
DATE EVALUATED) /r,�/
PROPERTY SIZE
ROAD NAME _�yY
Public 1/
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
8 r -5/pi-
S/ rTexture
Texturegroup
Consistence
/
Structure
k /!
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:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
DCHD (01-90)
Landscaue Position
EVALUATION BY: A U/
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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■ MMEMEMSEMMES MEMEMM MUMMIN MENNENHIRE
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