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219 Main Church Rd/ - •�� *� � a 0 6 DAVIE COUNTY HEALTHDEP{�RTMENT l.' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION&_ g Permittee -� Names t«'ti<i��;*''•- *;'s t� "" Subdivision Name: Directions to property: r' t' Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:#Q r'r>' E -Y-- - �. Road Name Zip: a .l **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 j< ; ; % '; ;i ar,'' ' ✓',!' 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 CQ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE B %S(k TYPE WATER SUPPLY A LJ DESIGN WASTEWATER FLOW (GPD)�� G NEW SITE—k—'REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ih) GAL. PUMP TANK GAL. TRENCH WIDTH 3Jl ROCK DEPTH /3� LINEAR FT. i REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT u "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 BY: OUV8// AUTHORIZATION NO. OPERATION PERMIT BY: JZ�j/DATE: J An�- "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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) DAVIE COUNTY HEALTH DEPARTMENT �� 4 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION c Permittde's�`,.i'� Names T �=t as, <r�' <' ° r' f' "' f f Subdivision Name: Directions to property: isSection: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name **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 # BEDROOMS # BATHS 5 # OCCUPANTS c+ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPEECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS I IINDUSTRIAL WASTE: Yes or No LOT SIZE &;7 4 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)`I-f�,/ NEW SITES REPAIR SITE SYSTEM SPECIFICATIONS: TANKSIZE//2, GAL. PUMP TANK GAL. TRENCH WIDTH "(� ROCK DEPTH ! v LINEAR FT. �I OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 5:7-111-X t� J D r rri V SPI _r A 00 c "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 DAA' OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT BY: /U';.— ';. �7y yl AUTHORIZATION NO. OPERATION PERMIT BY: s �/b� 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) Olt APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section �; P. O. Box 665 Iris EC E Q E Mocksville, NC 27028 APR 14 1994 1. Application/Permit Re ested By -1. 1 u 1,1 _ ' (A r I U ----------- Mailing Address Zo q L un- , 1-n S Home Phone o c Ks) `1 D a g Businesss,Phone—L34- 5 9 8 5 2. Name on Permit if Different than Above 3. Application for: 4. System to Serve: ❑ Business ❑ House ❑ Industry 5. If house, mobile home: Subdivision No. of People No. of Bedrooms a No. of Bathrooms Dwelling Dimensions General Evaluation Septic Tank 5d Mobile Home ❑ Other 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes _ No. of Lavatories No. of Showers No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: 2r Public ❑ Private 8. Property Dimensions , 7 �6 Ol G Sewage Disposal Contractor Instffllation Permit ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing 5 Washing Machine 27 Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: Go j $ - rl( k e4 4' re � �&- ©y-, V�Ct i ne v, I [ e- u. r d ham s e_ o &t e� A e eo.S> 1� To, "e. "A � -� e O -w o e k of, Ti b e a dPC, S-" 4-k `i Y,'�'d- �1ou,S e- a V 'C_ 4-0 Ole- e- r - S7v+-b 4 T" I e- a r iv e, S ` / Ir 13-0 q .1W#579obz -r1,� 16+ will / - _J-- `i ce //- -7K Rir Trr-D N�A -TV 17 � CRLc� This is to certify that the information provided is correct to the best of my knowledge, and I understand I am res bTe7or all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. p'2. 1 DO NOT OWN the property. 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 representat�jve f the Davi Qownty Health Dep ept to enter upon above described property located in Davie County and owned by2a to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. ATE 7t SIGNATURE DCHD (1193) io r �... DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well Community Public L -- Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z r -- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ee t 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 f LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: 1A_ 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 sloe 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-Very friable FR -Friable FI -Firm VFI-Very fine 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(01-901 ■��■■��■■��■■��■ ■��oo ■ ■��■��■■��/��■��0�■��i��v�■■ ■��■■��■�■�� ■��■��■��l� ■■ ■�■■��■��■�■�■��■��■ ■■ ■��■��■��■��■��■��■ ■��■��■■��■��■■■��■��■■��■ ■��■��■��■�■��■��■��r��■ ...........................................�...................... .......................................... ...................... .■................................................................ ............................�... ................................ ................................i�................................ ..................�........�...................�.■.......■........ ........................... ................... .................. ..............................................�........�.......... ::::::::::::::::::::::::C::::::::::::::::�':::.:�:_::::.:::::::�:: .................................................................. ...............................�..............■....■..■........■ ............................... ................................ ...............................................■........■......... ■��a��■��■��_��■■�� ■��■��■��H��■ ��■�� ■��■�■■��■�■��■■��■ ■��■��■��■��■�� ■�■��■��0��\��■��■��0��■�■� ■ ■■��■��■�\��■��■�■��■�� _��■ ■��■��■■��■�M��■�� ■■ ■■■��■��■��■■��■��■ ��■ ��■�■ ■■■��■��■N��■��N��n��\� �\��■�� .........................................................�......� ..................................................�...... ...... . .................................................. ............... .................................................................. ■�■■��■��■��s��■��■��C�■��■ ■��■�� ■�� ■�H��■��■��■�� ■��■��■ �� ■��■ ��■��■��■��■��■��■��\��■�� ■��■��iii�!��..=====��■� �■�\�■�■ ■■��■��'��■��■��■��■��ii��\ �� ■�� ■��a��■��■■��■��t��■��u��■ ■��■��■�,\■■��■■��■ ��■�� ■�� ■��,��1'iG1��■��■��■ ��r��■�� ■��\�■��■��■�� ■�� ■■■��■ ■��■o��■��■��■��■■��\■ ��■�� ■�■ ........�................................. ..... .......C........ ........�.....��...................... ..�... .. .�..�..�........ ........�.....�........................� ..... . .. .. ........ ....... �..... ......... .............. ... . ..�.�..�_......� .......��...............C........ .... .... .. . .. ...... ........�........................i1....�........ ..■........ .... .......��.................■.......■...■ �....�� ■........■._■..■ .......�...........�...................� ■� ■::::C......� .......�...■.......��.......■....... .. ....■ ...... ■��■11��N��n �� u��■��■�� ■��■��I��■�� ■ �� N■�� ..................................=S..S.�:��:� _��"_�::::::C: ■�■��U��■�■��N ��u� �=� ■��■��■��■��/=ii��i� -:ii � �� ■■■■■u■■■■■■■■..■......_�:.■■■�■■■■=■■T■� H�....nN■■■■■ ■�■��a�C:�ii��■��/f�l�■��►/�� N ■ �:� ��i� �� ■�i��/� �� ■��/.�w ��%��/%a!li�■��■��_�■ ■ �� ■�� ■ �r��-�- � 1 ■��■��I.IiII��iv��r----�...��i� ► �� ■�� ■��■��■�■��'�if1��.�.��■ �� \I��u� ��■�� ■�L��=�Giis��■��l��H�■��\�� r��I�/��u �� ■�� ■�� 1��7��A_Z!'L�'?./.r'/��N�■ ■��v��1��■��■'�■�� 1��\`V��f�f��//�� ■��■��■■��I�■��/�1��'1.��1� �1�\'��r�RIA//,%:ir��■�■�■ ■�■■��u�u��I��II�iI��l�ii�1<�l��I� �i'i�`��a/JCl1:�riZ�iii��/� ■��■��I■��%�N�11L�`I��/I� ��rl� �� '�� ■�� ■��N�r��l��t��i�■■��1�L ' ��■ ��■�■�� ■��■��i��r��i ��■�t��u��Z�n�� ■��■�■ ■��■��.�� i��■ ■��■��■��r.��r��■�� ■��n��i��■��r��r� ■i��►��u��■��■ ■��■��■��u�i�■■��■��u�■��■��■��■�■►��■■■�N��■�� ■��I�r��■ ■��■ ��I��Y��■ �/��■��■��I��II��=��iil�i��■\1■��■��■��■ ■��■��■■��!i��■��■�� ■�■�■��■ ��■��■��■ �� ■� ��■��■��■�� ■��■��■��■■�� ■■��■��■■�� CHARLES G. FOSTER DB. 66 PG. 513 NEW IRON PIN 100.00 2 Off,• `amu' Ste. •u'�9 aS�y Nlp 14 7.31 Ti1T7EA�W SUMEYM COAMMW FARMLAND ACRES 2i 7 L.ERTY ' NC�11 >7 / PL. BK. 5 PG. 201 \ MAINESVILLE AME ZION METHODIST CHURCH D.B. 16 PG.2 \ M44 PG. 427 \ \ S 54. 15' 27' E SA 1405 19.48 MAN CHURCH ROAD RIR SPurf ar nw" of t) \ � ��,,��pp i cc MQ4771 OF CENTER OF RA. IVR SPIKE Hs N IE' PAVED O � NIP NEV oM LIE ON LINE w 'y J O H h N AREA = 0.756 AC ti _AREA = O.756 ACRE } r LLAXIS SA 1405 RIW ��i�s• /O-� TAKEN FROM-- I TAKEN FROM d O D B. 90 PG. W D8. 90 PG. 321 6 D.B. 134 PG. 775 L N r��s Oto of cli n ,to v z CHARLES G. FOSTER DB. 66 PG. 513 NEW IRON PIN 100.00 2 Off,• `amu' Ste. •u'�9 aS�y Nlp 14 7.31 Ti1T7EA�W SUMEYM COAMMW FARMLAND ACRES 2i 7 L.ERTY ' NC�11 >7 / PL. BK. 5 PG. 201 Dam? Caunty Nealtfr e artment �Dy and .dome .hiealth Ay en ey ~ 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634.5985 April 21, 1994 Rhonda Grant 209 Country Lane Apts. Mocksville, NC 27028 Re: Site Evaluation Main Church Road Dear Ms. Grant: As requested, a representative from this office visited the aforementioned site on April 15, 1994. Based upon the information provided on the application for a 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