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223 Adams Rd�-.. .j:-,�� .-�`'-i. S sr'�� S�r,j�cK-4��i�� f- :�+:�.,.`T"M. . ..-Lf .�.ri. .:•i. �'1.�../ f' .�;.'.� w.�.�c. r>.. ,..f'_' i .-�t� . -y�� ....�_.-f »..-..:_r �� o-.=... r � �.Y�nt'Y`t;� AUTEi"dRI ATION NO: y� �� IDAVIE C UNTY HEALTH DEPARTMENT �J°�� ` �; � J `� A�� O / - , . Environmental Health Section PROPERTY INFORMATION ' Permittee's i ,�/ P.O. Box 848 Name: ��,f ��l:!�� 6.�i` r//f�/'y Mocksville, NC 27028 Subdivision Name: :.�..r ,�; Phone # 336=751-8760 Directions to property�� }°:f/%r'.%!! 1�� Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#�.,.%�.�- -��,5� -L� t� - SYSTF.M CONSTRUCTION ( ,,��.,/ ; �� f�i%%5 �� ' Road Name:,!_[/i/rfl>�'r Zip: **NOTE** This Authonzation 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ,i'J� ;.� ,,,. .�'" ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION `' %�? .�/,:l't,� /'�,�r-� � i' . j'°l IS VALm FOR A PERIOD OF FIVE YEARS. � ENVIRONMENTAL HEALTH PECIALIST DATE ISSUEb ,:.. .2,' �.1_ ._ f", .. .. .. ... . .. . ... . . . .. .. . . . � .. . � . . . . .. . . . - . . . . . . .. . . � � . .. �� ,,: i' 1 , . . � _ . � � �,� y ��,� ;� ' � �. ��. � R,a , � ;� � �� DAVIE COUNTY HEALTH DEPARTMENT `" ' ��'°� �,^ '` .. . , � TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION � � Perrn'ittee's �„ � � -- � � Name: �',��''~'!,�',�;`.�' �' .- !�.`- �- �' ' Subdivision Name: ,M _ ..�. - Directions to property:�, �' �'� Section: � Lot: .. IlbIPROVEMENT PERMIT Tax Office PIN:#�^ -� �� '3 ��a �r�s ✓�� P: , Road Name: .�°" �� : = Zi **NOTE** This Improvement Pernut DOES NOT authorize the construction or installaUon of a septic tank system or any wastewa[er system. An AiJTHORIZATTON FOR WASTEWATER SYST'EM CONSTRUCI'ION must be obtained frc�m this Department prior to the construction/installation of a system or the issuance of a building pernut. (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 TIIE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. � RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEDROOMS " # BATHS+�.'��# OCCUPANTS _� GARBAGE DISPOSAI�Ygs�r No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF✓SHIFI' # SEATS INDUSTRIAL WAS �i' �or No LOT S /�%. TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW (GPD) �.I.� J NEW SI"fE 1-�—'��REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/'�`�l/ GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH � LINEAR FI;j �v / OTHER Y'lJ�t��' �(./ n " � " �'/ �-J�l-r REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENTPERMITLAYOUT a�p�TD��p ��'L[lErIT FiLTGft$ $Crla'.�'g'�Z�Si �F E.�" E'�L.O� FIIIISIIYiD Cx�:Pi�A�9• S� /iC�'�i/t �° %1 Jil'�" r- C�J, ✓C **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 ('��34'&2bS��t t ??., ) 751-t1T6!� I OPERATION PERMIT � O a �,. SYSTEM INSTALLED BY: F AUTHORIZATION NO. _y�' 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 GNEN PERIOD OF TIME. DCHD OS/96 (Revised) � APPLI('AlION FUR SIIE EVAWAl1UN/IMPROVEMENT PEAMIT �C ATC � Davis County Health Oepartment �� • ` � �+� . . � Envfronmental Health Se�ctfon P.O. Box 8�8/210 Hoepital street i�Q� 2 9 �� Moakaville, NC 27028 �336) 751-8760 ElJYIRONh1E��TAL HFALTN QAVIE GQUPJTY �***2l�ORTAN3'**• THI3 APPLICATIdN CAPINOT BE PROCESSED LJNLE33 ALL THE REQOZRED INE'ORMATIOIi I3 PitWIDED. Refer to the INFORMATION SOLLETIN for iristrnations. ' G +Ssa Ei,4.Y-Je.c.� i. n�me co be $:.xaea �t2%GS�Ik Fc� �f s�Yl.�'. � c�tzat rar� �Foc rs-i-nc o� we. / 1 MailinQ Address ',�I S F�'d a.�� s 12o a c� 8� ��Q �,� (o - c.{.� Z_ S 3� 7 City/8tate/LIO t e 1, 0 �K- S d► ��. N C. 27 0 2� Basines� phone 5�YK e- Z. llame on Paait/111C i! bi!lerenb thaa 71bwe xalunq Amress csty/atate/zip s. Applicatioa Sor: U Site Evaluation ❑ Improv�oeat Pesmit/ATC � Soth �. syatem to servsce: � Honsn I] Mobiln Home ❑ Business 0 Industry 0 Other s. If itesicieace: � People I i Sedrooms 3 • Bathtooma •� � Dishwasher � Garbaye Disposal � ttashinq Hachine 0 8asement/pinmbiaq � Sasement/No plumbiny 6. if Snsineas/Zndustxy/Other: Specily type � people � Bit�Ya � Caomodea � 8hoxers # Orinals i Nater Coolers IF TOODSEAVICS: � 3eats Estimated Nater Osaqe lQaiions per day) 7. �`yps of water supply: 0 Conaty/City e. no you �nticipate additiona or e:paaaions of the facility this eyatem ia iotended to eervei If yes, what type' ❑ Comrtunity 0 Yes ;�No "**IMPbRTANT"" CLIENTS 11lUST C0,1lPLElE THL REQUtRED PROPERTY llVFORMATIO[V REQUESTED BELOW. �it6er a PI.AT or SITE PI.AN MUST BESUBMITTED by the cllent ett6 THIS APPWCATION. �1 �Gli.se s'�E'- � � U.� .po I'1.�1 �yro�t.. (�� Property Dimenaions: _ �(�� S 3 CiG VL�' WRITE DatECTiONS (fmm Mock:vllle) to PROPE�'I'X: S��- 33a -4xf2.s"3�� Ta: O(tice PIN: # 5 '� a. r% a'1 � �9 � �o $ �� !"�FJr��I. �c� �j �e-�t'l �Tc� � � �a� Pr+ope�ty Addr�s: Road Name �� Yw.S 12ou-� ��'�- '� n. G rc..�� I� �(( 'i-a S'ia p S� � City/Zip �DC�SVr ��e. NG 2?o2g �►c�Q� C�' S�D,p so q►1 � If in a Subdivl�ion provide ini'ormatioo, �u follow�: �,��"f' a ti% /�7�-�'►�-5 � G�� Name: S'�'��• GV I ��i�t ��.Gi ��i� o rL ��"t' c?v� v wh�� ho �e. en. �ef=F, Section: Block: Lot: Dste Property �lagged: a o'� I'�9 —�'�_ This is to certifp that t6e information provided is corrcct to the best of my knonicdga I anderatand thAt �ny permit(s) issued hereatter are subject to au�pension or revocation, if the site plana or intended use cbange, or If t6e in�ormation submitted in this application is �alsilied or changed I, also, Wnderstand that I am reaponsiblc jor all cllrmgu incr�rred fmnr t6is appluaotion. 1, 6ereby, give consent to the Aut6orized Repreaentative of t6e Davie County Bealt6 DepArtment to enter upon above described property located io Davie County and owned b�- �g n�2�vL oS7Q to conduct all testing procedures aa necasary to determiue t6e dte aaitabilit�. DATE 3,�`� I�f R SIGNATURE � TeIS AREA MAY BE USED FOR DRAWING YOUR Sl7'L PLAN (Inclade all o( t6e tollowing: E�ating �nd proposed property lines and dfinenaions, at�ucturea, aetb�cka, and :eptic locattiona). I �� `� �j� � �� w� Revised DCflD (07/98) Accouot Na yg`i9 d �'�� invoice No. � � � ' ,��,' � Adams Road S.R. 1 146 , � � ` ��;' , 45' R/W (Gravel) `'. ' '" �. ✓ose,ph J. Butzbach , , � � � ' i � S 3D'13'14'£ � i / D.B. 75, Pg. 53 z2.4 . i+,1 �� . � � , ' Apreed Ner Llne ' �� Nsr Llne' � � N S3'40'48'E ' � S 35•13'14'E 133.2 ' � � � • f2.S0' �' i - i / N / � 9 . . . � � � � i � , . . , / 'Aprees Comsr' ,, , � � wa+.r ' RMar s�l ; � = ation: 53 , F' , aa morkd 'Ayn�d" w�n o; Harf�r 0. HorNl and Jot�ph F�bruary <fh, 1999. Thit ayrw on a/ormal Ib» aQ►wm�nl pi :d oMorr►�r. � Butzbach , Pg. 53 bach 53 ,,, Xarley D. Nowell : D.B. � 77� Pg. 193 _.. s _ Fd �'qJ !i ' . F '�i . , . � F� , � � � i c 0 o � h Y o � ^ o O n � C V Re �f , / �,r�. �n� � 21.553 Acres � � � � � /� � Reba eet � _ � p , a zaao' (J�'Y" 3 Concnrs0 Fena Cornsr � In �rons plN P� .Q� � n c��.o ; RsDa o.� (Y�. e �oo' �� o /. v� ._ .�_.�. ___ � _ ... �.. ... �r _. . _ . �-.��..�iY 1�. � _.� . .. �-�.�-...-�._ . . J /�/ ' � 1 ' � /A '' o 'j �P� � �i � �i .; 8 �� P i � oa �' / P / --�' S4i /, f / , ,�� / o$ / JkQ Po�// P -� j,, � / U^° / � . / � � P ission �� - /� P�s ►oune —' g / �a� .P �nsm ,-�" a � �r / � ��0�er � �� m /,, /- ��o . / ' // P ' '/ ' �n �� N , �' P /' / � e , -� � ��/ ' / o / Reea sn P x-- x-- X x�� ' / , x _ � �� y, N B8°5/'A8'W 961.62' '-- 7C X— - Pipe �� / i/P. ,� ��x // o'p' l / jX ^ai� X /� oQ N a• `�� Snatr foune i .� y- � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT SoiUSite Evaluation APPLICANT'S NAME r��,�1)f�►� DATE EVALUATED 7!/�� PROPOSED FACILITY �J`� PROPERTY SIZE ��i4�` SUBDIVISION ROAD NAME /g �t'li� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring .Z� Pit Cut_ Slope % i-i(lRT7(1N T T1FPT�T 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 VFT - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Sligh[ly sticky S- Sticky VS - Very Sticky NP - Non plastic SP - Sligh[ly 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 Mineraloev 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 - gaUday/ft2 DCHD (01-90) ■�■■■ ■��■■ ■��■■ ■■��■ ■■�■■ ■��■■ ■��■■ ■■�■■ ■ ■ ■ ■u■�■ ■��■ ■�■�■ ■��■ ■��■ ■��■■ ■■■■■ ■■�■■ ■■�■■ ■��■ ■■��■ ■■■■■ ■■■■■■■ ■■�� ■■�■■ ■■■■��■ ■�■��■ ■�■��■■ ■■■��■ ■■■�■�■ ■�■��■ ■�■�� ■■■�■ ■�■■■�■ ■■■��■ ■�■��■ ■�■■�■■ ■��■■■ ■�■��■■ ■�■■■� ■��■■ ■�■��■ ■■■■��■ ■�■■■■■ ■■�■�■■ ■�■■■�■ ■■■■��■ ■�■■�■■■■�■■ ■�■■■��■■ ■■■■■�■■��■ ■��■��■�■ ■�■■■■■■��■■ ■■■■■■�■��■ ■��■��■■��■ ■�■��■ ■�■■�■■■■�■■ ■■■■■��■■■�■ ■■■■�■■■■��■ ■■■��■ ■��■■�■ ■■��■■��■ ■��■��■ ■��■■■■■ ■■■■■■��■ ■��■■��■ ■�■��■■�■ ■��■■■�■ ■��■��■ ■�■■■�■■�■ ■��■�■ ■■■■■■■■�■ ■�■■■■■��■ ■��■�■■■■��■■■■■■■■■■��■■■ ■��■■■■�■��■�■■■■■■■■■��■■ ■��■�■��■��■ ■ ■��■■��■ ■■■■■■■■�■■�■�■�■�■■■■■■■�■■■ ■�■