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360 Hillcrest DrAtrioRlzATiON No: 1334 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Permittee's ' 'X P O Box 848 PROPERTY INFORMATION Name: )� r�!`r 7C''�1 Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 Directions to property:Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# Z/ SYSTEM CONSTRUCTION Road Name: r S—'.Y ip: ✓xo **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 f':"' IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED .y 4 DAVIE COUNTY HEALTH DEPARTMENT t. = IMPROVEMENT AND OPERATION PERMITS Perma�te� s = Naive: 'mar Directipns to•property: PROPERTY INFORMATION Subdivision Name: Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name: 1'� ' r y ip: **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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 40.14 # BEDROOMS —7 # BATHS —,2—# OCCUPANTS--/ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE / (_ TYPE WATER SUPPLY (Vb DESIGN WASTEWATER FLOW (GPD) �, NEW SITE—1Z-- REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE /�, GAL. PUMP TANK GAL. TRENCH WIDTH ? ' ROCK DEPTH z� LINEAR FT. '(&) OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT "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: AUTHORIZATION NO. � OPERATION PERMIT BY: �c1DATE: "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 05/96 (Revised) 1 U APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERME. _= [ Davie County Health Department•; Environmental Health Section P. O. Box 848' Mocksville, NC 270288 - 6 (336)751-8760 i:.q..i ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES N ALL THE REQUIRED INFORMATION IS PROVIDED. Name to be Billed IJP'' OD i= Contact Person Mailing Address E, C Home Phone City/State/Zip /0,v,/-"., ZI 2 7/.,) y Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: Dishwasher ❑ Site Evaluation ❑ House "obile Home # People City/State/Zip ❑ Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms 3 ❑ Other # Bathrooms Both ❑ Garbage Disposal P -Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # Commodes If Foodservice 7. Type of water supply: # Showers # Seats P-"County/City # People # Sinks # Urinals Estimated Water Usage (gallons per day) ❑ Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes ❑ No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PkkTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: A'c _ I WRITE DIRECTIONS (from _ _ 1 Mocksville) TO PROPERTY. Tax Office PIN: # 7,5 S - 1./ Property Address: Road NamejG City/Zip 1 If in Subdivision provide information, as follows: 1 I Name: 1 1 Section: Lot #: 1 1 1 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 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 as necessary to determine the site suitability. DATE �—/- G - y 5�1/ SIGNATURE Revised DCHD (06-96) YOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. conduct all testing procedures _ �� . T I I �N� �� P� S \� I W �\ I o �\ ` \``\` I � J � � g ? SI7E \ � � \\ � 0.5"REBAR � � 5 Gt �. 0 P r � Z �' ^ VIC:R�TY MAP � 0 NO SC,ALE N �i . h v � 0 � m m h � v ti � Z NAlL AT � Q BENT E!P � � I CHARLES L. CARTER D.B. 106 PG. 850 � FAYE V. POTTS � D.B. l8/ PG. 5B9 I � � � i I I I II � NIP 27' TO i � � ROAD i i � S 65•3O'//" E---► N!P 2/7.B6 i Ni � to' � �� . � �� ; � . w ' i o 0 �; � �' o o AREA -�—-pp iqG,RE o o � i �; o x� CHARLES L. CARTER �' --- D.B. l08 PG. 650 � 0 i ~� o ^ o i W i 2 � 7��'�i X �°v � ° m �' ° o ' VI � � �; J � � �' i 3a �� mI I 2/7.B6 P!P?9' TO �— — /'+ BS•3C'//.. �.y, NIPNIP I � t�F ROAD /92.4/ N B5, ElP I30'/;" ;,y ' � SURVEY FOR : I ��'""""'''�� CHARLES L. C�ARTER I i ,,,`, C A R o �,,,, � ;�.`� .•••'•••�. �/ '�� I,GRADY L TUTTEROW,CERTIFY THAT UNDER RUTH L. HOCKADAY � ��:�G\STfl�'�r0�,G � MY DIRECTION AND SUPERVISION, THIS MAP �A�E� ��= 6O� �ROVED BY pqAWN BY D.B. lOB PG. 849 : O: � • � s : Z ; S E A L � _ WAS DRAWN FROM AN ACTUAL FIELD SURVEY DATE: 03/30/98 GLT �C � i � I ' L_2tJ27 ; ' MADE BY TUTTEROW SURVEYING COMPANY. Q� � 1 BElNG 1.000 ACRE TAKEN FROM THE CHARLES L. CARTE'R PROPERTY � ' (D.B. !06 PG. 850J L.Y1NG lN THE SHADY GROVE TOWNSH/P turr�ow �r�iro cows��rr ' " ��q ' l _ rt�ce�xrr c.r�[�c�r�xv j I �.tio v�� = , SUR � DAVIE COUNTY, NORTH CAROLINA :� �� _ NK' �2$ � � • f3.'�I �7� � Cf��' •.....••,`�QO�.` ` . I ��' 'Q Q r L. j�� ,w` C � ' .G U b p'✓ D R A W I N O N U M B E R I ��''��,.� R E G I S T E R E D A N D S U RV EY O R L-25 2 7 T A X M A P R E F : E-8 A P O R T I O N O F P A R C E L 7 O/ 6 7 9 8—3 � t �IN�IpIIt�LIlwrw�p No.isaw-��xs� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME l/!/bD�1� DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME 34 r Water Supply: On -Site Well Community Evaluation By: Auger Boring t/ Pit Public 1-"" Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure iL S K Mineralogy 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: 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 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 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 DCHD (01-90) ■EE■■ ■E■■■ ■■NE■ ■■■■■ ■■NE■ ■EES■ ■ENE■ ■EN■■ ■■■M■ ■EE■■ ■EES■ ■■■E■ NOOSE ■EN■■ SOMME ■E■E■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ NOON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■