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AUTHORIZATION NO: '� �� � DAVIE COUNTY HEALTH DEPARTMENT
��' � . ':Environmental Health Section PROPERTY INFORMATION
Permittee's ���r� j�,,,,. P.O. Box 848
Name: /'E�I��L Mocksville,NC 27028 Subdivision Name:
_' /Gt,� `�%1:� �.-�Cl�/I.'�LN Phone # 336-751-8760
Directions to property: fi`'� � Section: Lot:
a / ' AUTHORIZATION FOR r
�/" } "'�'� � � � �� ��� �� ����� SYSTEM CO STRUCTION Tax Office PIN:#� a Q - �� �
RoadName: LJI�-lii���:�ip:��
**NOTE** This Authorization for Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie Counry Building Inspections
Office when applying for Buiiding Permits.
(ln compliance wrth Artide 11 of G.SIChapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
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' j f ,..- r""""—'��., **NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
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_ i;f. L'��.- �� ��(._� ;`�--�-,. .- �.iY.� �� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTr�L�`HEALTHSPECIALIST� j DATE ISS�IED
. Y , . ., . ,. �: . . ,P . , . �,�� � ,1.,�� '� �U
� ' � ���,
� "' '��#� � -- : '� � � � DAVIE (`10UNTY HEALTH DEPARTMENT
z_'`�' ,: IMPRO'�'EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pes�uiti�e s'` � .,R .. � /
Name. - ����� �����������-- Subdivision Name:
Directions to property: f �' �'!�` � � , � � , .' ��``"� ��`'{ �•� Section: Lot:
' f IMPROVEMENT
�;. /,%', �`�J � �: � .��1 '' �,� .% jr.} r ►��� PERMTI' Tax Office PIN:� - �� - C7 �� j
RoadName: ��t-f�i��L� i�'Zip:��
**NOTE** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHOWZAT'ION FOR WASTEWATER SYSTEM CONSTRUCT'ION must be obtained from this Department prior to the
construction/installadon 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*** TiII.S PERNIIT IS SUBJECT TO REVOCATION IF STTE
•- / �,'t'; .; l•..--. , I�,(, ��;, PLANS OR TF� INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMEN L HEALTH PECIA�.IST, ;; DATE IS UED. SYSTEM CONTRACTOR MUST SEE TiII� PERNIIT BEFORE
� ,' : �,�:, INSTALLING TIIE SY5TEM.
RFSIDENTIAL SPECIFICA110N: BUILDING TYPE ��+�. # BEDROOMS �# BATHS �# OCCUPANTS �_ GARBAGE DISPOS � Ye or No
COMMERCIAL SPECIFICATION: FACILI7'Y TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE'���PE WATER SUPPLY � a T� DESIGN WASTEWATER FLOW (GPD) � NEW SITE '"/ REPAIR SITE
1 ,.,,,�-� r1 � � �,�
I
SYSTEM SPECIFICATIONS: TANK SIZE 1{�� GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH IZ LINEAR FT. �v
OTHER I �/ � S7��;.�'(J�� �"' YvT�
REQUIRED SITE MODIFICATIONS/CONDITIONS: � ��'2`T%Ll � C �vy� li�� ��'r't= 1' �' �� r �p1�t- , 1� (�i" � �+ ���`� .
- ' �C1.�f�, L,o�lv
' IMPROVEMENT,PERMIT LAYOUT
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*"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 930 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
�
OPERATION PERMIT
SYSTEM INSTALLED BY: �� h h% C..�1-�l
• � o {� L�`'� b°; i�`s�
v~' °1� � �, „- � r�''
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Ca l � 1� �. R� � g,. �
A U T H O R I Z A T I O N N O. � O P E R A T I O N P E R M I T B Y: ��� D A T E: 3 � �
••THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED W COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPUSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
�
�� APPLICA710N FOR SITE E1IAUlAT10N/IMPROVEMENT PERMIT & T:; �� � a� R--
Davie County Health Oepartment � l5
Environmenta/Hea/th Se�ction
P.O. Box 84B/210 Hospital Street
rso�x8v�iie, NC z�o2e SEP I 5 1998
(336)751-8760
***II►�ORTANT*** 'i'iiI3 APPLICATION CANNOT 8E PROCESSED VNLE33 ALL�Ti�-RE�v*�
INFORI�TION IS PROVIDED. Refer to the YNFORHIl,TION BtJLLETZN f�r instructions.
�. H� ��$i�i�a Cdd,-e n'1, =�-� he 11 ���t �9� 5�e�
Hailing Address �� �j �„ �U �p � W Some Phone ��/�- j� io �
City/State/ZIP � � 1 �C,�J v . `1 � N -C . �� � �gusiness Phone ��� � � � ��p
2. Name on Permit/ATC if Different than Abcve
Hailinq l�d�dres� City/State/21p
3. Application For: U 3ite Evaluation � Improv�ement Permit/ATC tt'Both
a. system to servtce: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Itesidence: i People �_ � Hedrooms �_ 11 Bathrooms �
�Dishxasher �Qarbaqe Disposal LiiTashing Machine ❑ Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/Other: Specify type � Peaple � Sinks
� Coanmodes � Shosrers / [lrinals � i:ater Coolers
IF z'OODSERVICE: # 3eats
7. Type �f Water supply:
Estimated Nater Usage (qailons per aay>
�i County/City
❑ iiell
e. Do you aaticipate additions or ezpansions of the facility this system is intended to serve?
if yes, w6aY type'
0 community
❑ Yes C�Vo
**'�IMPi(�IiTANT*=* CLIENTS ltlUST COrfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTEU
BELOW. Either a PLAT or S1TE PLAN AlUST BESUSe1tITTED by the client wit6 THIS APPLICATION.
rrnperiy Limensions: ��� Ac�'eS �WR�TE DIItECTIONS (from Mocksville) to PROPERTY:
Taz Ofiice PIN: # O O- S O-� 1, � � 0 ��-�- �..� -�-o (� �A �.. � (�
Property Address: Road Namc � � A-� (� K�
City/Zip (�in�Jc,�sv � � le � ,
If in a Subdivision provide informatioa, as follows:
Name:
Section: Block: Lot:
Date Property Flagged: � -1 � -�g
This e� 4o certify that t6e information provided is correct to the best of my knowledge. I understand that any permit(s)
issue� nereafter are subject to suspension or revceation, if t6e site plans or intended use c6ange, or if the information
submitted in t6is appiication is falsified or changed I, also, understand that I am responsible jor al! charges incr�rred fro�n
this application. I, hereby, give consent to the Authorized Representative of the Davie Couaty Healt Department
::.:.�.;:: upoo auove descri�eu proper"ry ioc..ie.: in �avie Louniy and owoec u�• L�� t- (� � e i � _
to conduct all testing procedures as necessary to dMermine t6e site suitabilitc.
DATE G — � � - �S SIGNATURE ���Lr�`-��-
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include ali of the following: Ezisting and proposed
property lioes and dimensions, structures, setbacks, and septic locations).
Revised �CHD (07/98)
Account No.
invoice No. ,���_
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1
1
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VICIMTY MAP
7t1n�r.ow sc�vEr�rci c.'o�NY
t21 L�ER'TY �RA�CF/ RCIAD
�ac.xisvu� w% �7q,.e
f�9Q) �-6Q'fQ
�ne���n ro.��s�-�un
� '
KENNETH LANIER
D.B. 76 PG. 453
- LEGEND -
EIP . EXISTWG IRON PIN
NIP . NEW IRON PLACED
................
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: ��:••'�ST fh ' C �'L �.
r 2'��QF.� f4��.'9?
�z� SEAt- _
' 's, ! L•2527 Q, F =
; �q�,� 5���'yo�•a �r
. C ��' • ... • �<.Q��.
� �� � V
• �Qr l. .��.•`�
I. 6RADY L. TUTTEROW , CERTIFY THAT UNDER
MY DIRECTION AND SUPERVISION , TMIS AIAP
wA5 DRAwN FaOM AN ACTUpt FIELb SURVEY
MADE 8Y TIRTEROW LiiVEYINC CONPANT.
1 ` i „� .
y���� .�: �,..
REGISTERE�S ND SURVEYpR L_ y327
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SUF2VEY FOR :
E�t�/E� -M�TCHELL
SCALE: r' = 60' APPROVED 8Y . DRAWN BY '
GLT
DATE: 06/12/9B MEC
BEING L322 ACRE TAKEN FROM THE' KEiVNETH L1WlER PROPER7Y
(D.B. 7B PG, 453) LYlNG IN TNE C1ILAHAW TOWI�[SH1P
DAV/E COCNT ; NORTH CARpL/NA •
DRAWINU NUMBER
TAX MAP REF : G-2, o porf/on of PARCEL9 1399�2
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�.� ,°� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME ��1�� /'Vl TC.�-}�—�'�-C, DATE EVALUATED ���
PROPOSED FACILITY �'�� PROPERTY SIZE � • � ��-�
SUBDIVISION ROAD NAME C��CA�-W �� .J
Water Supply:
Evaluation By:
On-Site Well Community
Auger Boring ✓ Pit
Public �
Cut
LONG-TERM ACCEPTANCE RATE: � ' �
OTHER(S) PRESENT:
REMARKS: � �_�? � � I
LEGEND �
Landscape Position
R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope
CC - Concave slope CV - Convex slope T- Tenace 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
Mineralo�,y
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)
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