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123 Parkway Ct Lot 22 1,i4 TKA C•e aaai.,i ..,.,w '+t .ro;, r ^f::..-..rp. AU:HORI ATION NO: 1656` DAVIE C UNTY HEALTH DEPARTMENT LL nvironmental Health Section PROPERTY INFORMATION Permittee's k P.O. Box 848 Name: � �� Mocksville,NC 27028 Subdivision Name: jPhone# 336-751-8760 Directions to property: ��+ r �� ���r��'�` Section: Lot: AUTHORIZATION FOR ;' t� �`.� t✓� l y© 7l J'J""� WASTEWATER Tax Office PIN:# �41 � --T tt SYSTEM CONSTRUCTION 1 ()N Road Name: CTZip: 97a **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) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION � /AA /o/Ax IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRON)vi5 HEALT SPFqLIST DATE SSUED �r -'x= Y�v'.• � 'T'� .. ,,,� .I � -,c.,. �,�'4•'M +'� a r . �-. arva,ew.e..,.•, DAVIE C OUNTYHEALTH DEPARTMENT TMPRO EMENT AND.OPERATION PERMITS PROPERTY INFORMATION ��Q Name:, Subdivision Name: ,Directions to,property:!e.!O El� I, 1 aU41 �' Section: Lot IMPROVEMENT AJC k1T), k. �C ' PERMIT Tax Office PIN:# ' s Jam ,.. - l . �. 'i Road Name: � Zip: �U **NOTE**This Improvement Permit DOES NOT authorize the construction or,installation of aseptic 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 .r ' (In compliance with Article I I of G.S.Chapter 130A,Wastewater Systems,Section 1900 Sewage.Treatment and Disposal Systems) �f r ***NOTICE*** :THIS PERMIT IS SUBJECT TO REVOCATION IF SITE.,' PLANS OR THE INTENDEJ>;USE CHANGE.YOUR WASTEWATER ENVD30NMEAiTAL EALTH SPECIALIST DATE ISSUED- SYSTEM CONTRACTQRWUST SEE THIS PERMIT BEFORE, INSTALLING THE S)t'STEM. ' RESIDENTIAL SPECIFICATION:BUILDING TYPE Ej0QS't#BEDROOMS #BATHS Z #OCCUPANTS -3 GARBAGE DISPOSAL:Yes COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY O/J� DESIGN WASTE11 WATER FLOW(GPD) iO_ NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE SAL., PUMP TANK GAL. TRENCH WIDTH �_ ROCK DEPTH 4LINEAR Fr. OTHER 4 -�T ��IJ f f0� /J�1C1r5 REQUIRED SITE MODIFICATIONS/CONDITIONS: J�'aIt" 0� G"TOJ/2 . �ZLG! S, DLFVIJc� ��p� oFF —7 I ��iJ4• �. �rJG. IMPROVEMENT PERMIT LAYOUT o 41 Ppb P 4.1�r. **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:001-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT w SYSTEM INSTALLED BY AUTHORIZATION NO. ! �v OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE. 77 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)-. � cul '• APPU(XfION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT V Davie County Health Deparbnent Q Environments/Mea/th Suction P.O. Box 848/210 Hospital Street SEP 18 PA Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH D 1 COUNTY ***I11PCRTANT*** THIS APPLICATION CANNOT IM PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed L061:r / r—Os.LnP Contact Person Nailing Address �,S / P��X !C-a� Esme Phone 3 6 ) 6 8a- -1-19 City/State/ZIP 1V I o c-4 SU/, t e JJC ;-�,.?-P Business Phone $aain e- 2. Name on Permit/ATC if Different than Above Hailing Address City/State/Zip 3. Application For: *Site Evaluation .Improvement Permit/ATC 0 Both 4. system to service: V House ❑ Mobile Home 0 Business 0 Industry 0 Other 5. If Residence: # People 3 — # Bedrooms 3 # Bathrooms Cr— Dishwasher O Garbage Disposal W washing Machine If Basement/Plumbing 1k Basement/No Plumbing 6. If Buainess/Industry/other: Specify type # People # sinks # Commodes # showers # Urinals # water Coolers IF FOODSERVICE: # Seats Estimated Mater Usage (gallons per day) 7. Type of water supply: County/City 0 Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ArNo If yes,what type. ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: /V o X 9J / a /0'4 /-?-� �ZZI SS- WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 6T 9D -.3a - 9/ /s' Property Address: Road Name 1'a h 9waq C4. Apra v a x 1 h'i L- -f-a o r-FA b rco L City/zip mocesul f!e • lU'G o n r 4-A P--1 /Q ., f ©in - If in a Subdivision provide information,as follows: sc:co n cQ 10•F- Name: A/ 4A g ro o K 6r"-) -00 e- Section: Block: Lot: eA Date Property Flagged: a I R I 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 FST _ _ � L- to conduct all testing procedures as necessary to determine the site suitabili — � DATE ,P��: THIS AREA MAY BE USED FOR DRAWING YO (Indo e I "fo : : Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. Revised DCHD(07/98) Invoice No. I ROADS ARE TO be j ' > , z '• i , `.. PER DAVIE C(;uN- r / f riY 5 Gf s ikr E" - M 60' FiIGYT-CF-t• • • ► NCDOT STANDARD I 1 L a ," • ' ALL PROPOSED 'v' 1 SHALL 6E i.E, 67 UTILITY c':&4p: �Q ' O/ f.�Dp ✓/Q i FIRE HYDRAN?S ' ` O• COUN 1' S-A;.DARD. In. 16502 FT. OF ROA TiRS PROPERTY PhOPERTY f5 CUr%r. 4.C1 0 QAC 3•. T. CRAIG 80GER. ALL LOTS TO NAv - D.B.HS PG.727. p j �•T •r� r`i r s ' I ZonN RA 6 R-20) - WATER TO BE P'=C` 'r,• 9 r ." d �"' ,- _ - ..WATER L;rJE J"•.LCiy6 1 J4` A T e 30,000 SOFT. MINI' o nAr NIUMUM SETBACK co 24.374 ACkF.S T: t en /� � � ' * T Q"" - 1.2 ACRS AV'cRAGF. +,. -• ` f r � �.. ,fit ,..�� �: �P-. �i� 3 J - y. fo - /'� X i •�� is rt �' / -.. - VV - _ Old rn X. 7. ,. ' ��.� it ,f .y „�Tt�e.O'.� z - Ka.• : '+ .w .dOw"r'-t,� t ., - - .. �• "� n S s ��� � �y _q / x's%�,�j' 6 r � it.Ly -�:.."' ' � -� ,.�� '' • t } - - .•S � .. �' x: I "�Y 1 _ , �}w` r.��'r ,�,� .r- �.�{ T �.f• r r ? V S Jf a :_ r "f a t. V - �� r �' � i f # 4 S4. �� i'.,.t''� �• �t- r « �� _ '+, rY�t �r :+ ,. . c �; .. t. � Y�.y'. 1•lM M 11 �. i Y i •.�n Y ,q� �yf i �.: -r -�?,�-. �ii.a•• r �-y�.,y k?'rrN` r:ii.._�' ..' 1. T �t i' � � s i y {_,_ M APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM v I I Davie County Health Department nr� Environmental Health Section SEP 1 8 19Z P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL 0AVI ,1. Application/Permit Requested By . a CS Mailing Address Home Phone !29,9#7 1 7 Business Phone 2. Name on Permit if Different than Above R 3. Application/Permit for: General Evaluation'' ❑ Septic Tank Installation 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ In Other R ❑ Unknown 2� 5. If house, mobile home: Subdivision ��� vRaa"se on Lot# ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing 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 No. of Commodes No.of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: 23"Public 7. ❑ Private O'Community 8. Property Dimensions 1 12-64a ?T, G 42eZZ1QJ Sewage Disposal Contractor 10 7 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? *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: d lQ/fL t':f' Cvv mL, c/LGvxlf/ � 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. DATESIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 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 representative of the Davie County Health Department 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 suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENTp�" Environmental Health Section Soil/Site Evaluation NAME �3TtJ� ►`� DATE EVALUATED Jt)- l o- ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By:(��I_ Auger Boring Pity Cut FACTORS 1 2 3 4 Landscape position Sloe Z - HORIZON I DEPTH Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure P2iK Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS .55 RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION .S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: S ' EVALUATED BY: LONG-TERM AACCEEPTANCE 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 .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 ■■■■■■..■■■...■■.■■■■■■■■.■■■■■..■■.■■■■■.■■■■■■■.■■■■■■■■ ■■.■■■■ ■■■■■■■■■■■■■■.■■■■■■■■■■■■.■.■■■■■N.■■■■.■■■■■■■■■■■■■■■.■.■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■ ■■.■■■■■■■■■■■■■■■■■■■.■..■■.■■■ ■■■.■.■■..■■■■■■■..■■■■■■■■■■.■■ ■■■■■■■■■.C■■■■■■■■■.■■■■■■■■■■■ ■■■.■■■.■■■■■■■....■■■■■■■■.■■.■■■■■■■■■■■.■ ■■■■■■■.■.■■■.■■■■■■■ ■■■■.■■■■■.■■■■■■■■■■■■■■.■.■■■■■■■■■.■■■■■.■.■■■■■■.■■■■.■■■■■■■■ ■.o■■■■.■.■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■.■■■■■■■■.■■...■■ ■.■■■..■■■■■■.■■■■.■■■■.■■■■■..■■■■■■■■■■■■o■■■_■■■.l■■■■■■■.■■■■■ ■■■■■■■■.■■■■■■■■.■■■.■■■■■■■■rm■■■.■■■■■■ ■■. ■■■■ ■■■.■■■■■■■■■ ■..;�■■■■■■.■■■■■■.■■■■■■■.■■■■■i1.1Pm■■■■■■.■■■■■■■■II ■■■■■■■■■■■■■ ■..t..■.■■■■.■■..■..■.■■..■■■■■■i�- I►w■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ CCCiiiiiiiiiiiiiiiCCCCCCCCCC■Cii�.■: iiiiiiiiii CCCC■MENN CCCCCCCC ■■■■■■■■■■..■■.■■■.■.■..■..%■■.�.�111.■...�■.■C�■■■■■■H ■■■■■■■■■ ■■■■.■■■.■■■■.■■■...■■..■../,■■■�'.■■\■■■■■ .■■ .0■CCCC■CCCCCCCC Mmmmm ■■■.■.■■■■■■■■■■■■■■■■■■■■■\1■■■u ■■mI■■■■N■■■■■■■■■■■■■...■■■■■■■ ■■■■■■.■■■■.■■■■.■.■■■■■■■■■\■&■.I.■■II■■■■■■■■■■i■i■.■■■■N■■■■■■■■ ■.II■■.■■■■■■■■■■■■■■■■■■.■■.■■■■i.■■II■■■■■■■■■■ ■ a■■■■■■■■■■■■■■■ mmimmmmmmmmmmmmmmmCCCCMCCCMCMMMM\MEPI-M EM �CCCCCmCCC■C MMM CCCC C mmiammmmmmmmCCCCCCCCCCCCmmmmmmmmmmmmmmmmmmCCCCCCCCCCCCCCCCC 1111 11 CCIlCCmmm■CCmCmCCCCCmCCm■omCmCCCCuCCCCCCCmaCo�■.■mmomm-�■CM■ CCS ..I.■■■■■N■■■■■■■■............................... 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