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221 Kennen Krest Rd �.��hy,�"3*`„j. ,'tp �$`.�"r, '.'r� ,'S"df+3f -2"' H A ii; +, ..f:' y�� i fe°g.� 4:i a :1i:.r� ✓. a i+ j'+ �s:r. w�i _F �y _ _._ c.,� S r d". �{}v' c"' 'Y '':y .q x FiJQ. GJ= • fA-4.5��tJ�V—� V AUTI+IORI�'ATIQ�f"NO: �fhl DAVIE COUNTY HEALTH DEPARTMENT PY Environmental Health Section PROPERTY INFORMATION Permittees - P.O.Box 848 Name: %', it%•r� ��I Mocksville,NC 27028 Subdivision Name: Phone# 336-751-8760 Directions to property: '� Section:' Lot: AUTHORIZATION FOR . WASTEWATER Tax Office PIN:#,!! 55 0 - SYSTEM CONSTRUCTION Road Name:': {7—Zip., Authorization for Wastewater System Construction MUST BE ISSUED b the Davie County Environmental Health'Section prior **NOTE**This A y y ty %f to issuance of any Building-Permits.This Form/Authorization Number should be presented to the Davie County BuildingInspections 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 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECI LIST', DATE ISSUED ' S-1 1 6 `A D_AVIE COUNTY I ALTH DEPARTMENT } - IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee=s 'Name: Subdivision Name: _ - ' -Directions to property: ' Section: Lot: IMPROVEMENT _ PERMIT Tax Office PIN:# " 120 - r 1 K" Road Name r'" +'W,Zip: ' . j#*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 F con struction/mstallation 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 l ri ^t �`,`•��„ ,; � `:, , � ',s• j'- PLANS OR THI;INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPEC 4LIST 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 #PEOPLE/SHIFT #SEATS IINND`UUSTRIAL WASTE:Yes or No LOT SIZE�/� TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD) �` NEW SITE r REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/D2GAL. PUMP TANK 41s GAL. TRENCH WIDTH .� ,,ROCK DEPTH LINEAR FT.. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT,LAYOUT *APPROVED EFFLUENT FILTER* R ) F 17 BELOW FINISHED GRADE* � sjig la � **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(7"§M*x x v OPERATION PERMIT 1 )) a SYSTEM INSTALLED BY: 46, �U AUTHORIZATION NO.- PERATION PERMIT BY: DATE: **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) . i APPU('AIION FOR 611E EVALUAIRIN/IMPROVEMENT PERMI Davie County Health Department D Environmental Health Section P.O. Box 848/210 Hospital street APR 2 9 1999 Mockaville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESSMWAMD INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed r ,, 54 b L� Contact Person 57 e, e�J / i Aa Mailing Address y�I k1PAIA �N /r�A.e4 7 sf24 Home Phone ��jl " 62W7 City/State/ZIP JU/��;S�1 Ile, Vy 'e, �/ Business Phone Z. Name on Permit/ASC if Different than Above Mailing Address City/state/Zip 3. Application For: A Site Evaluation 0 Improvement ,Permit/ATC � ��< .80"Both a. system to service: WHouse ❑ Mobile Home 0 Busineus ❑ Industry 0 Other is. if Residence: I People / Bedrooms i Bathrooms XDishwasher 0 Garbage Disposal washing Machine 0 Basewent/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/Other: Specify type I People # sinks f Commodes f Showers # Urinals # water Coolers IF FOODSERVICE: 11 Seats Estimated slater Usage (gallons per day) 7. Type of water supply: AY County/City 0 well 0 Community e. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes g No If yes,what type' ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BElSUBMITTED by the client with THIS APPLICATION. Property Dimensions: Qf— /N r 6 r,*'?37Y 37 WRITE DIRECTIONS(from Mochsvllle)to PROPERTY: 2S:.?1�2 6ad Tax Oflice PIN: # 6Dh v,b o� �'W �� iv �' 5 Property Address: Road Name kElyyfl K ' S l?l1 �e5 �ct- � 1 q )` QDa U�t n'��-� City/Zip k'Syf 16,x� 1 �/0 A- 7-6 5'�f F S;J X Allf 4J es, �ny'� l,e� t fi2ees iN �� f If In a Subdivision provide information,as follows: RCa Name: Section: Block: Lot: Date Property Flagged: C*AIL This Is to certify':hat the information provided is correct to the best of my knowledge. 1 understand that any permit(s) Issued hereafter are subject to suspension or revocation,if the site pians or intended use change,or If the information submitted in this application is falsified or changed. 1,aLw,understand that I ani raFonsible for all charges lncurred from this gp Ucation. I,hereby,give consent to the Authorized Representative of the Davie C unty Health Dep riment to enter upon above described property located in Davie County and owned by 5 to creduct.all testing procedures as necessary to determine the site itabilih.(��I&Ai*a'a'f R C d G i DATE ,��,� I I SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). IYry� k2 ep 5 r t� 97 `x' rv) 011 C Account No. -3 N 60 Revised DCHD(07/98) I„q �. Invoice No. 97 j 0 , + DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED , PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME Water Supply: On-Site Well Community Public J Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position .41— Slope% d�Ld � HORIZON I DEPTH el,i/ Texture group Consistence Structure Ly W Mineralogy HORIZON II DEPTH p Texture group Consistence Structure /L Mineralogy e 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 1 2 // SITE CLASSIFICATION: EVALUATION BY: l/ LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: if le'l 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 M is 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 Mineralog 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(OI-9o) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ecce■■■■cc■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■ ■■■■■■■■c■■c■■■■■■■■■■■■■■■■raw■■■■r��.ani■►■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■s■ccccc■■■s■■■cc■■■■■■■■■■■■■■■■ecce■■■■■■■■■■■■ ■■■■■■■■c■■■■■■■■■■■■■■crc■■■■■■■■c■■■■roc■■■■■■■■cc■■■■■■■■■■■■■■■ MEMNONMEMNONEMEMMEMEN ■■■■■■■■■■■c■■■■■■■■■■s■■■■ccs■■■■■s■c■■■■■■■c■■■c■■■■■■■■■e■■■■■■ ■■■r�■■■■■�:■■■■■i■ri■cocoa■■■.■■cc■■■■v■■a■■■�■�c.■ar�■■■■■■■■■■■■■■■ ■■■roc■■w■■■■■■w■■■a•�■■■■■■■■■■■►��■■■■cc■■■r�.i■�■■■_�:■r�■■■■cc■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■