123-129 Deer TrailDavie County Health Department
,•'y,, r"' ENVIRONMENTAL HEALTH SECTION
r P.O.Box 665
Mocksville, N.C. 27029
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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.***
�+ ��� AUTHORIZATION t�IMBER
NAME DATE
N2 :y
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION OlAdlz
COfENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
*mWICE*** THIS AUTHORIZATION F WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE
DCHD 10/95
,n
Y L --XO
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
LOCAT
SUBDIVISION NAME
LOT NUMBER
SEC./BLOCK NUMBER
0 --
RESIDENTAL SPECIFICATION: BUILDING TYPE WC�
# BEDROOMS C # BATHS a
# OCCUPANTS �,
GARBAGE DISPOSAL: Yes/0
COMMERCIAL SPECIFICATION: FACILITY TYPE
# PEOPLE # PEOPLE/SHIFT
# SEATS
INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY
DESIGN WASTEWATER FLOW (GPD)
NEW SITE
REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE &fid GAL. PUMP TANK
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
GAL. TRENCH WIDTH ZW ROCK DEPTH /J " LINEAR FT. VDD
S6' 1
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
IMPROVEMENT
IMPROVEMENT PERMIT BY
**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.
OPERATION PERMIT SYSTEM INSTALLED BY v
/3a
`D
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 10/95
APPUCATION FOP SITE EVALLIATIOIViIMPROVEMENTS PERMIT
Davie Courry Health Department
Environrnental Health Section
P O. Mix 665
v N 1 Mockoville, N.C. 210128
CONSTRUCTION SHALL NOT BEGIN UNTIL 1KIPR0VENIEN-TS PERMIT HAS BEEN ISSUED.
• Home Phgnp � -,Y-(/604
t,
1. Permit Requested By-- 0 .__' /itkI /L -h. ---___-- -- Business Phone __ I'll
2. Addre3s c ..� ! lL�rL� .. _� /9 d 11..✓
c _
3. Properly Owner if Different 11han Above _ 1 W�!> _. _ r..n��i�,.
Adiftew
4. Permit To: a) Install-lef-After Repair.,._
b) Privy Conventional-..- Other Type__.. 3 -
Ground Absorption
c) Sub-Q1vision-.171171i.__+ Sec..______.._ Lot No
S. System used to serve what type fa ility: House-- Mobile Home Eluaryess-___
Mdustry____ Other__.
b) Numbw of people____.
8. a) It house or mobile home, state size of home and number of rooms.
House Dimensions — —
Bed Rooms_.i_ Bath Rooms..._ -_0__-& ._._ Den w/Closet _
b) If Business, Industry or Other, State: Numtw-r or persons served
What type business, etc.._.._.
Estimate amount of waste daily (2•4
7. Number and type of water -using fixtures:
commodes garbage disposal
lavatory !/ -- showdrs __-�/_ r_.___--. _ washing machine -kms
dishwasher ._.,jam__._- sinks -_._-__--
8. a) Type water supply: Public_._- F'rivrge_,Y._. Community_
b) Has the water supply system boen approved? Yes___ No_kef",
9. a) Property Dimensions __ _..
b) Land area designated to building sit E: --
c) Sewage Disposal --
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What tyae?
This Is to cortify that the. information is correct to the best of my knowledge.
Date Owner Signature
OWNER 1$ SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 says for processing
Directions to properly: �~
Cab a d
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation
4. System to Serve: ❑ House
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms
Home Phone
Business Phone
❑ Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Other ❑ Unknown
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes
No. of Lavatories
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public ❑ Private
8. Property Dimensions Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If vas- what tvnP?
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ Yes ❑ No
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvementg Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
PKUP1i1,ClY 1Nr'Uiti` A11UN KL'' UIRLD:
Directions to Property: Tax Office PIN # _r _J S-71
Road Name JSnea,'l 2.9irc
Fox # (if available)
City
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
incurred from this application.
DATE
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. I OWN the property. ❑ 2. I 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 representative 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 said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1193)
r ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME YIJI/�'n /IArir DATE EVALUATED�3/�5�
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY A/ z LOCATION OF SITE A*0-24r- .4A
Water Supply:
On -Site Well _
Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS 1 2 3 4
Landscape position 4,
Slope R
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH d /'
Texture groupG�
Consistence r
Structure -c-
Mineralogy
CMineralo
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: EVALUATED BY: ,Xk&
LONG-TERM ACCEPTANCE RATE: ; OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscave 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- V+ --.-y 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
3C -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 (01-901
/0
LEGEND
WMROW SuRyffw; EXISTING IRC!. PIN
ROUIE 0 d.gNEW IRON
ETOLERANCES
1ACKEN
-ZC7T—,KEl FROM THE W BRACKEN
08.36 PG. 509),LYING I LARKSVIL
DAVIE CO, N.C.�t� � c� I
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r 12-1- 81
16581-2
I
Davre County Xealtlr Depanbnent
and Nome NealtFi .qyency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634-5985
December 19, 1995
Norman Dillingham
1219 Riverbend Dr.
Advance, NC 27006
Re: Site Evaluation
Boozie Lane/Site 2 (1/2 Acre)
Dear Mr. Dillingham:
As requested, a representative from this office visited the aforementioned
site on December 13, 1995. 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,
A 4 " V'j. /16 ed<7 4!; 7.
Robert B. Hall, Jr., R. S.
Environmental Health Section
RH/wd
Enclosure(s)