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133 Parkway Ct Lot 23 AUT14ORI7sATION NO: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permute@'s P.O.Box 848 Name: ; Mocksville,NC 27028 Subdivision Name: Phone#:704-634-8760 A Directions to property: 464A) 70 41L Section: i Lot: AUTHORIZATION FOR WASTEWATER- , Tax Office PIN:# [ - �- Cil JSYSTEM CONSTRUCTION `2 to it WAY f'T lw1 C0L.u,14C Road Name: Zip:' **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 apply ng for Building Permits. (In compliancejwith Article)4 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION J /fAl IS VALID FOR A PERIOD OF FIVEYEARS. ENVIR NE) AL AL A IST DATE ISSUED 'Tj�i��s _2� t,'.� �"1''e�. i:c::rti.,,,.+ai v*roY-a�-'.gyp '! "rJ•.,-.tM r.•.,� V r .. j i - ', 1 .. v. .. I 1302DAME COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION '{ . NaI F Subdivision Name: r Directions`to property: � Lot• 7 Section: „ IMPROVEMENT PERMIT Tax Office PIN:# zJ_ G•l 'fir, 135 t"1", IS C t!L Road Name. Zip: ' **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system of 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 comphance,wiol,6mcle J1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE `'7 PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE TMS PERMIT BEFORE ENVIItbN1IEI�b7'AL ALTII SPEGIAI.IST DATE ISSUED INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE 1 #BEDROOMS 3#BATHS 2—#OCCUPANTS 2 GARBAGE DISPOSAL:Yes.<O, COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS ✓INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY�0�?n17 DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE t SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 3�v/► ROCK DEPTH JZ/ LINEAR FT. � OTHER `-s�QllTla� REQUIRED SITE MODIFICATIONS/CONDITIONS: r'+•-i= l D` ` pp,�Z, F-F1! (O DT `K+SCGr-Ty ( ani if- IMPROVEMENT PERMIT LAYOUT 75/x .751 '75'. �L. 132 e • 1 a- "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FORWAL 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 A K GY SYSTEM INSTALLED BY: a 1C. CA^�'te4tTo� �lC� �'STa� n � AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM BED ABOVE EN 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 i • APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE n Davie County Health Department 0 �j Environmental Health Section P.O.Box 848 APR _ ' 19% Mocksville,NC 27028 (336)751-8760 CZ;1.t0�::!FJffAL 141;1;�i# ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES DIIS ` rs4''I = AL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Contact Person Mailing Address Home Pho City/State/Zip Business '70fhof—WZ9,-72—S' 2. Name on Permit/ATC if fferent than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation * Improvement Permit&ATC ❑ Both 4. System to Serve: J House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People .2 # Bedrooms - # Bathrooms _ Q]i 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: J County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes i No If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A ft THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: . ��/.��f 1 WRITE DIRECTIONS(from _ 1 Mocksville)TO PROPERTY: Tax Office PIN: # 1 Property Address: Road Name 1 1 _ City/zip 1 _ If in Subdivision provide information,as follows: ; 7 Name: A20 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 Represe tive of the Davie C unty Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures Ix as necessary to determine site suitability. DATE -Z' SIGNATU Revised DCHD(06-96) YOU MAY USE THE BACK OF THIS FORM FOR bRAWING YOUR SITE PLAN. r Y -23 c9 le 41 AL J �, P, QRY kAYzLIP C /00 - 1 .gyp �j- 1 •" �'S •:c �l-'.a t - L2 AC. ntb UAJI. Po� 161- 1A Ns, 151 4b4p ` " - N 0.7 AC. r Q - • ._ .� _ _ '7 �; s�:;.s�� V P ,ryYIN',- -39 �\ .v - - . ,�,' _ - p Off• O$` Vic,. yam/ ��b O 0.7 AC. {;�' ' ie•td R�ckS _ ,o r� . {� t. ski 0.7 AC. Pl. 0.8 OJAr- Lu .6s � , � -��, -gyp' � •—��' N .. � n� - .Q - - , APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department Environmental Health Section SEP 18 19Z P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL 04VI 1. Application/Permit Requested By Mailing Address Home Phone !29,9# 7 Business Phone' I; 2. Name on Permit if Different than Above l` 3. Application/Permit for: VGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: �ouse El Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Indust Other ❑ Unknown a3 I 5. If house,mobile home: Subdivision I 00 vtaa�Se on J- Lot # aw ❑ 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 f 7. Type of water supply: E"Public 7. ❑ Private ❑ Community 8. Property Dimensions � � ,,��G . G dcaWz Sewage Disposal Contractor 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: 4 d 1 '&,' 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. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: 1. I OWN the property. ❑ 2. I DO NOT OWN the property. ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment al system. DATE SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation p NAME DATE EVALUATED ADDRESS S� � PROPERTY SIZE �f I 'V PROPOSED FACIILTY O�.a9. LOCATION OF SITE a iffiy ((�+2D a)F= Water Supply: On-Site Well Community Public V Evaluation By:C� Auger Boring Pit k- Cut FACTORS 1 2 3 4 Landscape position Slope %_ -I3 HORIZON I DEPTH t' Texture groupL Consistence F Structure Mine ralo ;1 HORIZON II DEPTH Dr Texture group Consistence Structure K Minetalogy 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: •�• EVALUATED BY: LONG-TERM ACCEPTANCE RATE: t� OTHER(S) PRESENT: ��i7 N•Q 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 :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Ve.-y friable FR-Friable FI-Finn 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 ■■■■■■..■..■■■.■■■■.■■.■■■...■.■■..■.■■■■.■■■.■■■■.■.■■■■■ ■■■■■■■ ................................ ................................ :CC:SCSSSSSSSSS::SCSCSCSCCSC::SCSSSSSSCSSSSSSSSSSSCCSCCCCCSSCCSCSS ■.■■■■■■■■■■■■■■■■■■■■■.■■/■■■■■■■■■■■■■■■■■■■■ MEMMEMOMMEMEM ■ESE M MINN .S■■■■■■■■■■■■■■■■ ■■■■.■.■■■■■■■.■■■■■■■■■■■..■.. ■■■■■■■■■■■■■■■■■■■■■..■■■■■■■■■ SSSSSSSSSSSSCCCSCiiiiiiiiiiiiiiiiC=C�C■iiiCCSCSSSS■SCCCCCS=SSCCC=C iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiC■CCCCCCSSSe■iiiSCSCSCSCC■SSS='C■C ■■■■■■■H■■■■■.■■■■■.■■■■■■■■■■■�■■■■■■■NS■"■.SSSSSSSSCS�=SSS ■■■■■■■■■■■■■■■.■■■■■■■■■.■■■■■■ ■■EM■■E■ CCC:SSSCCCCS::SSSS::::'■:C::::C:::::C:SS:SCS::::. 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