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163 Dakota Ln .. , 4 • H ..y' \s a (. 1. a. .. ♦ .. • i ., t .- .. - i. ... ��0. !. DAVIE COUNTY HEALTH DEPARTMENT i IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT74 lox z **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater qy,-cjd system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the WBS construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of 6.5. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) / NAMEc„�/�i,#Y 7i7/ /�,��rn PROPERTY ADDRESS� DATE LOCATION mv) SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE_ # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yefilo COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE lflC' TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD). NEW 5ITE Y/REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE LIZ GAL. PUMP TAW GAL. TRENCH WIDTH -7V 'ROCK DEPTH V' LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MIST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. 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 # I5 (704) 634-8760. i OPERATION PERMIT SYSTEM INSTALLED BY F 1 Y (•i !ny ` Q Q� A.vn q QI AUTHORIZATION NO. d O �fl TIDN PERMIT BY DATE **THE ISSUANCE OF THIS OPERATION PERMIT '� THAT THE SYSTEM DESCRIBED ABODE 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 _ „ t Davie County Health Department �4 ENVIRONMENTAL HEALTH SECTION R. V P.O. Box 665 r d� Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) , H �K 4 This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior toWS16 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 NUMBER NAME DATE 62 4 e 1�/_. N2 i f I G NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION 4`5/ J &k -/_ — CONTENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*** THIS AUTHORIZATION F S WATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5)-YEARS. � Ave, ENVIRONMENTAL HEXTH'SPECIALIST DATE DCHD 10/95 .,r. ...� ..,�..W�....�?:w�_,. _• `r,.... .n+' n _ e.3+3+ - _s+.K:-+X }__; is S APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE W p Davie County Health Department Environmental Health Section L2 1 1995 ' ! + P. O. Box 665 Mocksville, NC 27028 tili l lfF1. .,4 1. Application/Permit Requested B C.CSZL✓ &I-K, Mailing Address Home Phone O Business Phone to 3 'C;I 2. Name on Permit if Different toan Abov -" 4 Rto-74'1 - 3. Application for: ❑General Evaluation Qa�eeptic Tank Installation Permit 4. System to Serve: ❑ House VMobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing . No. of People � ❑ Basement/No Plumbing I t No. of Bedrooms ❑ Washing Machine ! No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ��, ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks 3 No. of Commodes No. of Urinals I: No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures i 7. Type of water supply: EY Public ❑ Private ❑ Community 8. Property Dimensions y 0Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 8'No If yes, what type? 'NOTE: Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. f Directions to Property: PROPERTY INFORMATION REQUIRED: Tax Of f ice PIN # �L , 61 Road Name Box (if available) W WJE. L►`R��-c)`''-' a✓v�Com. C it yQC �I � 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 i. CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. C12. I DO NOT OWN the property. a 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 represent 've of the Davie unty Health a ent 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 suita 'lity for a ground absorption sewage treatment and disposal system. I_q5 OWI., DATE IGNATURE I t DCHD(1193) 1 F. WILLIAM PAVIP POOIE, sp . ...._.-r. 00,95 Po.799 36 al 29 473 i 49 376 27 579 29 293 u Ou•n W- E --'�III It row. • -.x�y 1 �..�.�. ...M ._._._ 26561 fYl N a, A , ` S r% .0 J w a vv 41, of vO/ 1`JT \ o P�p y 6N d\ CP 04 \ i '• 4Pn \ t A r w (� -1141 y' � \S J EE z�znn� uhf ��94• `jl p0 E• E'. 6as101 y5 �4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation /�! NAME DATE EVALUATED / 1�) ADDRESS PROPERTY SIZE � G PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring C� Pit Cut FACTORS 1 2 3 4 Landscape position Z �' Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH �- Texture group Consistence Structure 4h /C- Mineralogy h" 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: 17G� LONG-TERM ACCEPTANCE RATE: I 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 <;lay 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 SSSS■■■eeeee■■Eee■■eM■■E■M■.■■EMe■NeeE■eee■■■■■e■=■■eee■■■ ■■�■e■■ ■ecce■■■e■■■■■■■e■SSSS■/■e■■EeeNE■■nee■■■■■eeee■ ee■■■■eeee■■■■e■ ■■■eee■ecce■■■■■■■■■■/eee.sS■M■■�i■■EEE■■■e■=■■■Ne■■■■■N■e■■■eS■e■ ■■■■■■■■NSSSS■■■M■■M■ME■■■■NM■■■■■■■■■NM■Nee NEENNNNEM■■■eENEMNEM■ ■■■■■■■■■■■■E■■M■■■■■■■■N■OO■■■M■O■■O■■■■■■■O■■■■e■■■■e■SSE■■■■SOMME ■e■ MEN mmummomm ............................■... . ................. .MENEMMSMEEEES ................................ ■■MMMMMMMMM■■e MEMO ■�■�■■■■e■■■■e ■■■e■■S■■■s■■Se■ce■■■■■Eac■■■■■■e■■eece■■■e■ee ■SNNE ON 0 0 on EM■MEM sm=M■■MM■ ■■■a■■■■■■■■■■■c■ec■■NEE■e■■■■■■c■■te■■■e ■■■ ■ ■ ■e■ ■E■ ■■" ■■ ■■e■■e■■■■■e■eee■e■■■eee■■=S■/ee■eS■■e■E■"�ee■= c"��=NN■I ESSEN" on ■ceM■c■eee■■■■■■eee■■■Oce■ ■S■■■■■■■■EMEE■■■EEe■S E■M■■■MESON■eeec ■■ENec■eeMMNN■■EENNNNM■Ec■■■■■■■ ■e■■■■■S■■■■■■s/■■■■■■ENO■■■■■■■ ■e■■■e■eNe■Nc■eeeeee■eee■ee■e■■ ■/oeee■ue■■eeS■■/a■■e■E■eME■OS■ ■■■■■MN■M■■NE■NNO■OEO■E■■OOMSS■EON■■eOS■MN■E■E■III■�MEN OMEN■■MN■E■ ■■■■■■■■■ES■■■■O■eONMO■■M■■O■■■■■■Oe■■■■■■■M■■■ NNE eOMEN■■■■M■ ■eee■■M■■eee■N■e■e■e■e■eeeeeee■eO■■e HE■/ ■SEES■ /MUMSONES on ■e■eee■■■■■■■■e■■■■c■ec■■e■■■■■■■■=■�i■■■■■=■ uN■■■e■■ ■ ■■■■■_� ■eee■■■SEES■e■■■■■■■■■E■■■■■■■■■■■ ■■EM■■eee■u■■MENE NE no ■ ■■.eee■■■cNNMNCNMceM■NNMeeNNceecN■Sc■c■E■■■e■■E■E■ ■ ■e■■■e■■ ■■c ■■O■■■■EMMN■■■SE■■ONM■SNOONMONO■�OeN■■■N■■�S■■■uu■■SNE■■e■N�ENO ■■ONNeMS■■NSeSOS■SSNNOSENMMNSSSSSNNNNOSSE■SS■SS See■ SOMEONE■■/ ......■■...■...■....■.■■................■■.....■ ■■ ENO OMEN E■N■ ■See■■.�� ■■MMN■■MNSNN■■M■NNNNMMSM■SMNN■■MOSMNMSNNONSNNS■■ ■ ■e■■■■Ne■e■eee■■e■■EN■■■e■■■■■■■See■e■■■■fie■■e■e=C mol ■NNol■es■e■■EO■ SSSS■SONO■■■ENENNSO■■NS■OOEOENNOSO■■O■■■■ M■■EM M■■■E■■ SN■NE■E ■E■NE■■■■cNESMMceNNENUNMCN■eMMN�MMceu■=eMEuuuE■eNNEC■■NONE■N ■iei■v■i�eiiiei"■i ■iiiiiiiiiiii ■eiieiiii■iiiiei�"I MME iir Mmmommom MIMMEMMEM iS■..iS■..Si■..iSM■..i■■■..Ei■..Oi■■O�i■■■Oi■E■■i■■EMiieaONiOD■u■■EU■■Mie■S■i■■■■i�■N■i■NEi■■■O■■■ii■EcEi■■NESe�NO�e■■Meie■O■■c■ui■=■S■■■■�■S�ie■�i■■i�■S■■■■■=�■��■ie ee■�i . ■EN■■ ��iiMiaiiii■ iiiiii"/m IN MENNEN ■■■/■■N%■■ M■ SHEEN■■ on ■■■■N■■ ■ M MENEM �■■ ■■.eee■■■■■N ■■■■MMM■■M■MM■ ■■M■■ N= No ■■■M■■■■ ■■M■■N■eMEE■EE■■■■■■■■■■■■■■■■s■ MN■u ■ ■eN MENNEN M IMENN�i"MEME■ENE=EEi=NNi eE a■ii isiomi i ■E■OMONEE�■e■■E■E■■U■ SE■■■Mye M■ NN ■■■■■■� ■■See■■ MEMNON Emommome■■■ ■■See■eeeE■e■NEONe■e/KNEE■ N 0 m ■■ e■e■■■■i ■■■MSNO■MS■NM■MH■SO■■NSSOOE■MES ■N � EOi■■EuE MEMO ■■eeauEmommom■ ee■eMMMMMMMMMMMMMMMMMM � ■mom momommoommoommo MEN ME 0■E■ ■■■ ...■... MMEmilmonnmm=mmmmmmm M SM M 0 mommommom ■■MNNNONMSNOMNSMO■ONE■NMO■OMMOEi� ■■■ ■ no MM1M mm==MN ■e■■eE■■■■ EMMENNE No MEN ME no No mmomm�imm N MMENEEN M�No 0 SO0CE■NOME ■MMMM■ MMMMMMMMON ■■ M"�■NUN■■ ■EMO�0 ■i■■/ ONE miiiieSmiiiiiuii Et ■■E I■ i■NMMMMMMMMMMMMmi MMM■ ■■Mir ONE M�■■ ■■M■■M ■M■■■■■uEM■MNN■N■ EOSNONN■N■■E�.SMO/�O�OO��OMMI«�v��N/�■■S■e�M■��O�ESEOE■■eO ■■C:�CO::iNv■■ESOMN� ■��N��v�� ■SON■.■■�i��:..0:ME■/OMS ■■■■DMO■■MNNNNSNNSNN■�■■■■■■■■■■■■Oe■■�■MOO■ENNNN■MNN■OE■■■SSNMM■ ■NNEe■■■NMENMMM■N■■NMN■MEM■MNEN■■■■■eMUN■■NN■NM■M■uMEN■N■EN■NN■■ OMEN iiiii■i■iiiiiiiiiiiiii■iiiii---MEN�No MEMMOMMEMEMOMMENUMME 0 IIiiiii■ iiiiiiiiiiiiiiiiiMNi�■ieiNMi�ii�■i■�iiiiiiiiiiiiiii Davie (amnty .7�ealt`r Department and dame NealtIf .fyency 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE.N.C. 27028 PHONE:(704)634-&94W420 January 5, 1996 Scott & Tanya Clemo c/o Swicegood-Wall Attn: Sharon Cohen 300 S. Main St. Mocksville, KC 27028 Re: Site Evaluation Highway 601 Korth/5.001 Acres Dear Mr. & Mrs. Clemo: As requested, a representative from this office visited the aforementioned site on December 29, 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, Robert B. Hall, Jr. , R.S. Environmental Health Section RH/wd Enclosure(s) E z i