196 Calvin Lane Section C Lot 13�, .a ;j'-.,etbe a-`f>,S .e1�.snaz�ik .. yaP>Pw .; a+-�; �. . s,r, .r'.� s ,•:lit. r «.M fa c.>z:a._.,.- ._ ,r: .,. ..,.-3, a
AUTHORIZATION NO: 17 4 2 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee'si _ } P.O. Box 848
Name: - - =�-� -' fit-t-►�A Mocksville, NC 27028 Subdivision Name: Ot t trAl (.R
Phone # 336-751-8760
Directions to property: &%o � �� o �' � ^� � Section: Lot:
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN: # #—S
Road
7y iG� -
Road Name:IGSc'n% 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 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.
ENVIRONMEAL HEALTH SPIrIA IST DATE SS ED
1742 DAVIE OUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permitt i
Name: �J:a.�'i .w_.-1Gt-yv; t,ti1 Subdivision Name: 11a
r
Directions.toproperty /;' t. J �-I C, Section: Lot: l '
IMPROVEMENT ,
PERMIT. Tax Office PIN:#
Road Name [:=r �_ ri zip:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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 G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** TMS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRON E AL HEALTH SPECIALIST DA ISSITED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE# BEDROOMS -� # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or vo
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE IoTYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ,lo NEW SITE REPAIR SITE
rr rl �
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT. �Y
OTHER L`��T K -I QtJTin ?�r7S
REQUIRED SITE MODIFICATIONS/CONDITIONS: tai SIAL L o A GC�N l ooz 14rcP 1&64- Fa'OP Ll r_( 's o(- F
r7J L
IMPROVEMENT PERMIT LAYOUT
------ P2cP L.iJr-
�Vltii x-
�'
N
"*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.
OPERATION PERMIT n
V�
G
Y�
fig
901P
BY: V U 54j /
u
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: o
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 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.
DCHD 05/96 (Revised)
APPl1CAMON FOR SITE EVAWATION/IMPROVEMENT PERMIT do ATCVMVIROVDITAL
�] [
Davie County Health Department
• Environmental Health SmWon
P.O. Box 848/210 Hospital Street CT 1 3 1995
Mockaville, NC 27028
(336) 751-8760 HEALTH
***IIWORTANT*** THIS APPLICATION CAMWr 1W PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed S 41;1,0.Contact person
Nailing Address ' Iq I gonia phone I O
City/state/ZIP , Z4 4� 2702` Business Phone
2. Name on Permit/ATC it Different than Above
Nailing Address City/state/Zip
3. Application For: U Site Evaluation 0 Improvement Permit/ATC *r3oth
4. system to service: 11House 'Mobile Home 0 Business 0 Industry ❑ Other
s. If Residence: # People_ # Bedrooms # Bathrooms
0 Dishwasher 0 Garbage Disposal thing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/other: specify type # People # sinks
# Commodes # showers # urinals # Nater Coolers
IP FOODSERVIC8: 11 Seats / �Estimated Nater Usage (gallons per day)
7. Type of water supply: Id County/City 0 Nell 0 Community
e. Do you anticipate additions or expansions of the facility this system is Intended to serve! 0 Yes 0 No
If yes, what type!
***IMPbRTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN AIUST BESUBAIITTED by the client with THIS APPLICATION.
Property Dimensions:tyLi -- /DO. X oto do
Tax Office PIN: # -9 / `f ) •-
Property Address: Road Name & Lo'&
City/Zip ICI (, ( S Yt Ve- 2262 J
If in a Subdivision pro de information, as follows:
Name: L .
Section: lock: Lot:
DIRECTIONS (froom] Moclie) to PROPERTY:
117 1 7e C—
Date Property Flagged:
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 l an reVonsiblefor all charges Incurred from
this appUcadon. 1, hereby, give consent to the Authorized Representative of the Da Co ty He th Dep a (meat
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.
DATEy j J / r SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/98)
—,
Account No.
Invoice No. �d
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT 13
Soil/Site Evaluation
APPLICANT'S NAMEVO�IUA��A
DATEEVALUATED �J
PROPOSED FACILITY rV" �6��^' PROPERTY SIZE loo 7C
^7C D
SUBDIVISION i1f�L,1174Y %3 ROAD NAME 4, � _ -
Water Supply:
Evaluation By:
On -Site Well Community /
Auger Boring Pit ,/
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
L
Slope %
o
HORIZON I DEPTH
Texture group'
Consistence
S
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
$
Structure
k
Mineralogy
HORIZON III DEPTH
_L10
Texture group
t-srDC
Consistence
Structure
ISNie
Mineralogy,I
HORIZON IV DEPTH
-
-S
Texture group
Consistence
Sid
Structure
Mineralogy1:
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
42p
.
SITE CLASSIFICATION: �S
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
DCHD (O1-90)
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
tructure
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
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■11■■■N■■■■■�■■■■■■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■11■■■■E■■■■■■■■■■■■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■■■Nil■■e■■■m■m■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■■■■11■N■mS■■■■■■■Nom■■■■■■
■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■ ■■■■■■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■11■■■■■■■m■■■■■■■■■■■Nilo■■■■■■■■■■■■■■■■■■■■
MEE
ONE
■■■
MNEME■11■■■■■■■■■
■■■■■■IIMENNOMEM■
■E■■■■11■E■EM■M■■
■MMm■■IIMM■■m■M■■
■EM■■■11■E■MEME■■
■E■■■■11■E■ME■■E■
■E■E■■IIME■■■MEM■
■■■■■Mil■E■M■■M■■
■NNNEEII■E■E■■■■■
■M■E■■i1■M■■■■M■■
■MMEMEII■M■M■■■■■
■E■EMM11■M■MEMEM■
■■■■■■11■■■■N■■■■
■■■■■■11■■■■N■■■■
■■■■■■11■■■■■■■■■
■■■m■■11■■■■■■■■■
■■■■■■11■■■■■■NN■
■■■■■■11■■■■■■■■■
■■■■■■11■■■■■■■■■
■■■■■■■■■I
■N■■■■■■NI
■NOMMEN■■1
■■■■■■■■■1
■■■Nil■■O■N■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■■■■■■■■■■■■■■■■■■■■
■■■Nil■■
■■■MNIM■
■■moil■■
mommlimm
■N1N■NI■■
■ItVmilm■
Nil■mil■■
■ommil■■
■■■Nil■■
■■■■KINE
■■■mit■■
■■■■NI■■
■N■■NI■■
■■■Nil■■
■■■■NINE
■■■■lel■■
OMEN
MEMO
MEMO
MEMO
NONE
MEMO
MEMO
MEMO
SEEN
OMEN
■■■■
■■■■