120 Old March Rd Lot 2 { • i --' td�. -`i•' 1 a t,' s• ...: a .a 9'.
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AUTHO'RIZA1'ION NO: DAVIE COUNTY HEALTH DEPARTMENT �x o
vet'•-y'°'�� Environmental Health Section PROPERTY INFORMATION
pees. ..-iGJP.O.Box 848 . f
Name / Mocksville;NC 27028 Subdivision Name: —VC v
Phone#:704-634-8760
Directions to property: t rl ` Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#' �4 `- _ eo 4/
0
SYSTEM CONSTRUCTION
Road Name. AL10149-4
r 4.D Z a ULA'
-**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)
yj,. ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS
ENVIRONMENTAL HEALTH S CIALIST DATE ISSUED
-UNTY HEALTH
DIMPROVEMENT
ND OPERATION PERMITS PROPERTY INFORMATIONRTMENT �o'
Name''' t`c ' / A Subdivision Name: ";t ✓ k�0`tl �`
Directions to property �' ` 4` %f '4'('"�/' �� Section: /� Lot:
IMPROVEMENT
PERMIT r
t�l: � �:Tax Office .•�•!5��j
1
Road Name. p�' tstr
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTE4I'�I CONSTRUCTION must be obtained from this Department prior to the .
4 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 THIS SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE/! #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY_� DESIGN WASTEWATER FLOW(GPD) NEW_SITE_ '� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/&j�)—GAL. PUMP TANK GAL. TRENCH WIDTH Z�l ROCK DEPTH ,L-2 LINEAR FT.
OTHER
REQUIRED SITE M0151FICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r
**CONTACT A REPRES VEOF DAVIE UNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9 0 A.M.OR 1. -1:30 P.M. N THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: h t� LV►
v
qo
AUTHORIZATION NO. / / OPERATION PERMIT BY: DATE:
*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
L—�j
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY 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 PE Atr
Y. Davie County Health Department
Environmental Health Section _ 8 MW
P.O.Box 848 t�70
Mocksville NC 27028
ENVIRONMENTAL HEALTH
AVIE****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed D/ & NDi-/ZB Ot)66y-sr ..-Z C . Contact Person -��C /-f tlO $Di(/
Mailing Address 401A16- /-4L/4Z-A/ LA/. Home Phone ' 7s 7 n
City/State/Zip � IOC s C 7CU a Business Phone 3-31-1gV-7d.7 7
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: i#deti V Improvement Permit&ATC ❑ Both
4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
Dishwasher X Garbage Disposal Washing Machine 0 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: X County/City 0 Well 0 Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PXA MTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: RQT doe q / GIV CC_OScC� 1 WRITE DIRECTIONS(from
_ Mocksville)TO PROPERTY:
Tax Office PIN: # S 7 g - - 91 % 1
Property Address: Road Name P,--;0ACE�(iPr,-r-k P-0_ 1
City/Zip ADi/AAX.=-. AlrV
C a-700 6 '
' 7ZU2.A! L t=T a N
1
If in Subdivision provide information,as follows:
Ab 4699MMMM
/�/� 1 K
Name: /r lA�2CH �ODl�S 1 r
� mrc�a
Section: Lot #: 11 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. 1,hereby,give consent to
the Authorized Representative of H.the Davie County Health Department to enter upon above described property located in Davie County
/ V
and owned by S'- Woo r--c, to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 6 es
r 7 & SIGNATURE
Revised DCHD(06-96)
YOU AtAY USE THE ]BACK OF THIS FORM FOR DRAt4INC7 YOUR SITE PLAN. /,I r• a
IAI
• ' �,- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTIoN_,L_LOT
Soil/Site Evaluation
APPLICANT'S NAME J�'lf®?�_ DATE EVALUATED
PROPOSED FACILITY )) PROPERTY SIZE
SUBDIVISION /�i'314� fit?�rl d� ROAD NAME
Water Supply: On-Site Well Community Public G- --*,
Evaluation By: Auger Boring Pity Cut
FACTORS 1 2 3 4 5 6 7
Landscape position .L G
Slope%
'HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence r
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 ,
SITE CLASSIFICATION: Tn-, 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)
SIDNEY F. HOOTS /
D.B. 175 Pg. 507
----- % i' N 33.47'22. Er ___ `ruL / Qq•
J , 231.61 / ' 2 �' s� / Q0 Gb '
/
8 / o
A. HOOTS
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5 Pg. 504 \. \ °Za' ♦ / LOZ -''#7
49
110
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C3 09L
770
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d- 13534
CD
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NOTES /
ALL LOTS ARE SUBJECT TO DAME COUNTY
HEALTH DEPARTMENT STANDARDS.
2. ROADS ARE TO BE BUILT TO NCDOT STANDARDS
BEING A PUBLIC ROAD WITH A 60' RIGHT-OF-WAY