3569 Hwy 601S Lot 1 i}''� y�'e-r ♦ '��. :��. �, 3 i II r, {.� 1 r •:�' ,� �. ::-7�,,.!i '�'.aL ,T :v.,tr ' Ys?E'"r v,+.—!'w �.;.cr..,.:�i"w ""s Y'.Y-�r .?.
21/),(10
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AU'r No: '� �j DAVIE OUNTY HEALTH DEPARTMENT
'• �""`� Environmental;Health Section PROPERTY INFORMATION
Permittee's % • P.O.Box 848
Name: - as X` 1 Mocksville,NC 27028 Subdivision Name: 4.
/ Phone# 336-751-8760
Directions to property: '; (, �i�:`� /fi'' Section Lot: l
AUTHORIZATION FOR
WASTEWATERnw
- SYSTEM CONSTRUCTION; Tax Office'PIN:# -
oad Name: !/l0 /7
Ll b
**NOTE**,This Authorization for Wastewater'System Construction MUSTBE 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)
`***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
- IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED'
= ' 1616 DAVIE COUNTY HEALTH DEPARTMENT ,
IMPROVEMENT AND OPERATION PERMITS. PROPERTY INFORMATION
Permlt[ee;s
:Name: <' - Subdivision Name: -►
�.� ,° --
�Dlrections to property: J` Section: Lof: �ICA
IMPROVEMENT
= PERMIT Tax Office PIN-#
n oad Name l[l0
**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***TI IIS 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�&#BEDROOMS #BATHS _#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE " #PEOPLEISHIFT Jc #SEATS '"v INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY L•C� DESIGN WASTEWATER FLOW(GPD) 6U NEW SITE REPAIR SITE'
SYSTEM SPECIFICATIONS: TANK SIZE/" GAL. PUMP TANK GAL. TRENCH WIDTH .�G ROCK DEPTH �G LINEAR FT. 3�y
;. .
.. OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
4 C0�� W'
r
.. r
r
**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 (336)751-8760.
OPERATION PERMIT,
YSTEM INSTALLED BY:
��
�� �
AUTHORIZATION NO. OPERATION PERMIT BY: C�"`� DATE: /y
**THE ISSUANCE OF THIS OPERATION PERMIT SHALLINDICATE 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).
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI 1i
T9 9 91 U
Davie County Health Department
Environmental Health Section I
P.O.Box 848 A 1 4
998
Mocksville,NC 27028
/
(704)634-8760�.. 1 I �• EN1f1RDAV1EEC0UNT ITN
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
J ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Contact Person Pw
a.7 4�
Mailing Address �+ Home Phone �(
City/State/Zip �� C� %y fy 0 ! Business Phone U ��� I
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: / ❑ Site Evaluation t/Improvement Permit&ATC ❑ Both
4. System to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
!9'Dishwasher ❑ Garbage Disposal U Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats3/County/City
/ Estimated Water Usage(gallons per day)
7. Type of water supply: C/ County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 03" No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions:
l3i 1 WRITE DIRECTIONS(from
1
Mocksville)TO PROPERTY.
Tax Office PIN: # 5155 _ .zp _ 3350 leo
1
Property Address: Road Name W0I
City/Zip 1 1 I dl/Y�y� Vii a�yz0 1 Mp 11
1
as- -
If in Subdivision provideinformation,as follows:
"" 1 G!► FAV/
S I Jx�Do d 1
Name: 4 cp'"
/ 1
1
Section: Lot #: 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 /H�ealtthnDeepartment to enter upon above described property located in Davie County
and owned by_ 0 "t " `,`�' A to conduct all testing procedures
as necessary to determine the site suitability. r
DATE 7-13�V'U SIGNATURE
Revised DCHD(06-96)
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
Davie County Health Department 'Mp
t w
Environmental Health Section PAY
P.O.Box 848
Mocksville,NC 27028 , ".i"Y.:T► .ta °►t
�'t►' F
((336)751- -8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed G/-\ TW &:e L,L LkC C1 Contact Person
Mailing Address 7-00 .sok o)) G�✓2cN Qa A►� Home Phone
City/State/Zip ✓►'(y C IL,S ll ►LLE C 2-70 Z Business Phone 336-
1
3L
2. Name on Permit/ATC if Different than Above J O s I t=. C Q S r
Mailing Address 20o 130X J00►' C&Iy CM 2 Q City/State/Zip 191 J CIL, J►L'Lc 1 NL Z/028
3. Application For: g,Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: House YMobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: County/City ❑ Well / ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? Q Yes ❑ No
If yes,what type? IJ EJ 5y 6 p%\I I S aI'J L-O-r S 11 L4 51 �0
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A%6&W THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: `- A T T,&.C 1-\` 1---) pL&' t 1 WRITE DIRECTIONS(from
1 Mocksville)TO PROPERTY:
Tax Office PIN: #
3350 1
9,9 1 v S tool S o v T I-1
Property Address: Road Name 1
1 F2 U M /�o UGSJ,c..t_� Tv�Q KO
60)5 City/Zip O
* Ll 5� �� 1 s�L►.J dv" p�i1CcL ►S
If in Subdivision provide information,as follows: �.�" !� o 0 .
tr y ca r�yJ 600 1 4
Name: dos,L g 1
Ovro de 60X vVeo
Section: Lot #: 1 O 0o Ltsrf
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 n I C gAR-Q f3 CR-4 �� t to conduct all testing procedures
as necessary to determine the site suitability.
)ATE
5 11. 5$ SIGNATURE
Revised DCHD(06-96)
YOU MAY USE THE 13ACK Of THIS FORM FOR DRAWING YOUR SITE PLAN.
197.03'
ry DoJ"L�_=-
pC
�o O C
�° 1.303 Acres +/— 2 N 0.9.3
Acres
Sv
235,00' N 2f� °``�„w 145.00-
246 78'
� A
c8
�ry
ry O N rr
1.591 Acres +/— ;ti 1.712 ,
v
L
26o
607
�1 s 7?' .�245
.11,
N 16°0715„
a� An
D
kliUne
lintenterr Line
EP — Edgs of Pavement
FC— Face of Curb
PP— Power Pols
ht Pols
H_= n PRELIMINARY
Ra lug stance
lugChord Distance
P 0 — Port of
S —SigM Easement
oe - pat Book NOT FOR RECORDATION,
PB — Plat Book
C8_—catch Basin
�S—
once 0, DEEDS, OR BUILDING
BoC — Ck o,Curb
100 200 300
DAVIE COUNTY HEALTH DEPARTMENT
" r-- Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME C �� �I GLZ/Cr�/ DATE EVALUATED
PROPOSED FACILITY /� �8£� PROPERTY SIZE
SUBDIVISION ROAD NAME O -s 0 CI 0,0
44,
Water Supply: On-Site Well Community Publicy ACL
Evaluation By: Auger Boring Pith/ Cut ,
FACTORS 1 2 3 4 5 6 7
Landscape position .L J_
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
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 L
SITE CLASSIFICATION: EVALUATION BY: 4/
LONG-TERM ACCEPTANCE RATE: 7111, 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)
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Boxwood Church 1z;oad
FK-Noi Found in
%,pprox:rnate C_ S.R. ;824 . 1824 Tie _*0
Tie Line S 85°22'0 "Y/
S 83030'0011W
32 10' 60' Pi,olic R/1,'V 20'+1— Pavement — — 8.35'— �
5 27021'30"E---- 667.03' Totat
Control Corner 197.03' _ iRS 45.00' TiRS 145.00' ;RS 80.00'
IRS/Set near r' ' _. t 4:.. u,,:_,,. r,
Concrete Monument 1
& 2&112- E;P ^v y
CO
IRS ao !-
L.F.3u acres � ►� ;
Contra Comer
o � ` U q u I-
tq4
,•�,'o,' 12.4s• IRS ''r `�
-:son
52 •
v W ro I Z
10� a
E,P Bent
IRS 125.47 V!R / --- S 85°
ti 145.00' IRS ;
—1� w ° lRS 108.70 6
` N 3245"W
15;.
91 �
�l ' ! 227.28' ' Nl 21°32 45"' l 'Ra
/r��
Acres ^ JJ
Ina-
292-95' cnc
rL . Golda
G
IRS '
roto/ ( Q 157
WO/ '-� 212
� N 6
_ '15"W +.RS 102 B1 9- o' r:; .-v�• r:.
Tie Line �,`+ c:
83030,00`E 60. flub/' �'�� `� IRS o . E»
30.42' 1c R/W 20,.j-1 _ r
j,.�, — _
C/
�ZFovemeni
W(,Z& Tie Lane
F-20 0
N 85°40';0''E
•v„� PK—Nail
shed Classification: N/A ,x.67'
Foy?nJ
_s shot' be served by public water
:s shall be served by on site private sewcge cisposo: systems
?ities shalt be instched underground
um Building Lines: Front Yard: 40 feet '�^a ro•
Back Yard: 30 feet F;gnt-0( `of i (09 o C':; 659.
Side Yard: 15 feet Coa_Ks. 6Fna Pic c;:ar:CE
subdivision area: 8.479 acresS6.E•;
number of .ots created: 7 lots `'' Z '"Z;4a " is 4z
i _.J ;6•�..'15w 38.65'