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158 Hope Ln;_ , � f';�,�� ;�; i� ��, � `k: -��; .. _ . , . . y � o A.�iHORIZdatON No: `�� C� t� DAVIE COUNTY HEALTH DEPARTMENT � � �- „' ' t , Environmental Heatth Section PROPERTY INFORMATION Permittee's d �; � P.O. Box 848 Name: ��i/ � ' W�' ��'�"-* Mocksville, NC 27028 Subdivision Name: �'fc��u� ,,rr +-� "� l) � �.�, Phone #: 704-634-8760 Directions to property: � � ! +�S�t`r: �"l�+ � � ' - Section: Lot: AUTHORIZATION FOR ��,% WASTEWATER i�' ,o!/j .^,.' _;!,�^'�" SYSTEM CONSTRUCTTON Tax Office PIN: �.�� -�� -...,....�,-•:.. 7 �� r� � Road Name: �:'i7..��.�:-%.f�! ��: � .� **NOT'E** This AuthorizaUon 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 Pernuts. (In compliance with Article 11 of G.S. Chap[er 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 'AL HEALTH �[,�'***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCI'ION fJ IS VALID FOR A PERIOD OF FIVE YEARS. DATE ISSUED .._ ., ._ . . .- . ,-Z . . _ . . . � : . _ . . . __ . . , . ..: t f�1 J � �'� , / r! � r�) 'r` «�• !' y t 1 0 , �..� af� . . . . . . . , . . '�:.(� i% . , J.,'K .. .� � ' t., ; ' G '� i Q"'S ! � 1 '�`�- �-� �T .+ . � ,�'w � � DAVIE COUNTY HEALTH DEPARTMENT ��` �.'l ;�` � TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION . Pe �Iee'-� � �; v.`. ,.� . . . Name: �'R? . �''""' R';� � "��'' "�i!;:�'`""` Subdivision Name: � +-, �� , � +". - 1! �i ✓ Z•! i- ..,�' � ` . .- .-_�_--._ . . . .. „ ........ ` Direetions to proper"ty: �..-� j,� x;r` '`.�1 r%' `�'' Section: Lot: A` IMPROVEMENT r' d PERMIT Tax Office PIN:��+�-"� �=„� _- ��.`�,�-,. - =�.- � ; --' � � r � �f 'J Road Name:�':`"'.�� .�; �'�d��r�' �-�:t�Zip� c;, ':%�., r **NOTE** This Improvement Pernut DOES NOT authorize the conswction or installation of a septic tank system or any wastewater system. An AU'I'HORIZATTON FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from 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) . , r . ; ,� / ;> �- ,. ,� ; `; '�. £� ;/,,� ,-°; `� � > : a�,,�` `f;�r, �, ,;s ;y j , .' „'! `�,> ' f r � M ENVIRONMENTAL HEALTH SP�`CIALIST DATE ISSUED ***NOTICE*** THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TEIE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE Tf�S PERNIIT BEFORE INSTALLING THE SYSTEM. RFSIDENTIAL SPECIFTCATION: BUILDING TYPE ��'� # BEDROOMS �# BATHS �� # OCCUPANTS �_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFTCATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE /� TYPE WATER SUPPLY �/" �/r DESIGN WASTEWATER FLOW (GPD) �-� �� NEW SITE � REPAIR SITE �c� �' SYSTEM SPECIFICATIONS: TANK SIZE �/j/,� GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH �y�%� LINEAR Ff. ��%� � OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT .-...._�� **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 830 - 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: _L�U ��J�,,,, � Ic� �NG.� � �� AUTHORIZATION NO. OPERATION PERMiT BY: ! DATE: � l—� d **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAP'TER 130A, SECI'ION .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 OSN6 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC � �'�'�'�IMPORTANT* *** Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 THIS APPLICATION CANNOT BE PRO � � � �� '� �:,j. I I FEB - 21998 ;i"} 1;':r r..- �p 2�i.1.�i��Y�. THE REQUIRED INFORMATION IS PROVIDED. ,� �1 , I j� r`�, �'�` 1. Name to be Billed �,�-� � Cl_i11 �\ ►"��\ C�� Contact Person� G,�� -1�d��G�� tv� Mailing Address �� l � nC� �,�'� � Home Phone ��- ' �- o�� City/State/Zip ��Z%C�� )��Q , 1�1�1• a%�� Business Phone 2. Name on PermidATC if Different than Above Mailing Address City/State/Zip 3. Application For: [] Site Evaluati [� Improvement Permit & ATC j�Both 4. System to Serve: [] House [�obile Home [] Business [] Industry [] Ot er 5. If Residence: # People a # Bedrooms�_ # Bathrooms [�shwasher [] Garbage Disposal —�-' [t}/Washing Machine [] Ba e e t/Plumbing [] Basement/No Plumbing 6. If Business/Other: Specify t� # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimate�ater Usage (gallons per day) Type of water supply: [] County/City Well [] Community Do you anticipate additions or expansions of the facility this system is intended to serve? Yes �J No If yes, what type? �CJ� S � Y1 �" �' �'��-� EZTHER tt �'LttT OR SITE PL.tLN PROPERTY INFORMATION REQUIRED: *** IMPORTANT **'��i.�'�' OF THE PROPERTY MUST BE , SUBMITTED WITH THIS APPLICATION. Property Dimensions: 1� C'�L2 , �� WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #�Q.� - � - �J�J o�, � ; oO � l� . -�p �->�2� C� (� �%., Property Address: Road I'�Tame � � � ��-�' � � �r C-�� C�'1 � ��`� cicy�z�P ��c�� 4 Q 4 ; ��k- �o � � � � �Zd o r� (�-�r-, -�i,k- If in Subdivision provide information, as follows: � �� '� �d � � � � `� �' Name: � �CA--�e.�- �.�'li � � � �u�e.. o n Section: Lot #: ' ��'�- �aU�� W � � w n� �� ., - - - n � _ _ �- �-11.� .,L1 _ l _ n 4.". � \ .�,. : �.-. This is to certify that the information provided is correct to the best of my knowledge. I understand that any pertnit(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 I am responsible for all charges incurred from this application. 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 �(�� f Q,,%�- �Cu2A2 to conduct all testing proc dures as necessary to determine the site suitability. DATE��_ SIGNATURE � �- � 1 \ Revised DCHD (06-96) THIS ;1rrt1 ��tlJ $E USEb �OR bRttIUZNC JOUR SZTE YL�iN: ,• t,�• . DAVIE COUNTY HEALTH DEPARTMENT �` ' Environmental Health Section SECTION LOT SoiUSite Evaluation APPLICANT' S NAME �� '✓ � L�C DATE EVALUATED ._�s/I �/� O � PROPOSED FACILITY %J�Y PROPERTY SIZE / �G� SUBDIVISION ROAD NAME ��''�'i �hC�c`'�SP1r`. Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut_ SITE CLASSIFICATION: � EVALUATION BY: ��-G'� LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R- Ridge S- Shoulder L- Lineaz 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 �rm 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 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) ■■ ■■■��■■ ■■■■■■■ ■��■��■ ■■�■■■■ ��■■ ■��■■ ■�■�■■■ ■��■■ ■��■ ■��■ ■■■■ ■�■■ ■�■■ ■��■ ■��■ ■■■■ ■�■■��■■■�■■■ ■�■■�■��■��■ ■��■■��■ ■■■■■■��■■�■ ■■■�■■■■■■�■�■ ■�■■■��■■■■■■ ■��■■■■��■ ■■■��■■��■■ ■■■■��■■ ■��■■■ ■��■��■■01'1c'i�■ ■■■■��t�i��■ ■��■��■■t�■�■ ■�■■■��■■■ ��iiii:!� ■�■iii��■�■■ ■■■■�I��■■■■■■■ ■�■■�'�■■�■��■ ■■■��■ ■�■�■■ ■��■■ ■��■�■ ■��■�■ ■■��■■ ■�■�■■ ■ ■■■■■�■ ■■��■ ■��■�■ ■��■■ ■�■■■■ ■��■■ ■�■■■■ ■��■ ■��■ ■■■■■■ ■■��■ ■��■ ■��.�� r�r�Y ■■■■�■ ■ � ■ i ■■�■��■�■■ ■��■■ ■��■■■��■ ■■■■■■�■�■ ■��■��■■■ ■��■�■■�■ ■�■■■■■��■ ■■��■■��■ ■■■■■■■■�■ ■��■■■ ■■■■■■��■ ■��■■■■■■ ■■�■��■■■■ ■■■■■■��■ ■��■■�■■�■■■ ■■��■■��■ ■��■�■■■■�■■ ■■ ■■��■■ ■■ ■��■� ■��■��■■�■■ ■��■■■■■��■ ■■■��■■e ■e��■■■��■ ■■��■��■■ ■��■■■■��■ ■■■■��■■■� ■��■�■��■ ■�■■■��■�■■ ■■■■��■■ ■�■■■■■■■■�■ ■��■