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137 Northbrook Dr Lot 12� -:1 Fri�:�)� '� ��,.a�iy,v r �„�„.y .-t; tp. , �.; .[ },r. ...,,+ .. � ;ya _ 't� `• > r.;� W 4�d"y�J.rt ii�!x ACTH ntzATloN No: (�, DAVIE. OUNTY HEALTH DEPARTMENT Z✓ko Environmental Health Section PROPERTY INFORMATION 3:'14 Permittee's P.O.Box 848 Name. '1 r Mocksville NC 27028 Subdivision Name: f , ,✓ / Phone# 336-751-8760 Z Directions to property:- fi A/CD f' ` Section: Lot: AUTHORIZATION FOR WASTEWATER Tax OfficePIN:# � V_ ! - W SYSTEM CONSTRUCTION ��1 �0 Road Name. t *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;l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage,Treatment and Disposal,Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALIDFORA PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ! 4 3, DAVIE OUNTY HEALTH DEPARTMENT, ✓rac'p IMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION :r H Name: - j Subdivision Name: Directions to property:, - f' .! , Section: Lot:: PERMIT Tax Office PIN# L/G pQ Road Name 't A^ 1p:� **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 cohstruction/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) THIS PERMIT IS SUBJECYTO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.. ' RESIDENTIAL SPECIFICATION:BUILDING TYPE _ #BEDROOMS_ �� #BATHS�_#OCCUPANTS J_ GARBAGE DISPOSAL:',Yes or No ,. COMMERCIAL SPECIFICATION: FACILITY:TYPE #PEOPLE #PEOPLE/SHIFT // fir#SEATS INDUSTRIAL WASTE:Yes or No ��....yyqq.f�,,A I jC�Z : LOT SIZE/r� l� TYPE WATER SUPPLY '�D DESIGN WASTEWATER FLOW(GPD) ( a NEW SITE_ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE fQQZ_GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 5 LINEAR FT.. 3Lv! OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �+ ... Q�)re lir a **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 (336)751-8760.; , OPERATION PERMIT. p 10. SYSTEM INSTALLED BY: :c 100 AUTHORIZATION NO.— OPERATION PERMIT BY: `/ DATE:. 2 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT S M 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.. t DCHD 05/96(Revised) e 1. APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&A Davie County Health Department 2 r Environmental Health Section AUG P.O. Box 848/210 Hospital Street Mocksville, NC 27028 EWIRONMEMAL HEALTH (336)751-8760 DAVIE COUNIY ***ndPCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. actions. `I /� 1. Name to be Billed �� (�( p{e��1 1 1 Il ty(��Contact Person 2�y',I, ' o V_ c� 1� Mailing Address -7I-`/� l (,noon l_Jtl\�P I ±X Home Phone City/State/ZIP '► r \�} I (�� a'I IMB.siness Phone ��-r- 2. Name on Permit/ATC if Different than Above -'-y-1 ry)P Mailing Address city/State/Zip 3. Application For: ❑ Site Evaluation w/improvement Permit/ATC ❑ Both 4. System to Service: House ❑ Mobile Home ❑ Business .°❑ Industry ❑ Other 5. _Iff Residence: # People �_ # Bedrooms # Bathrooms _ N Dishwasher ❑ Garbage Disposal V'Washing Machine ❑ Basement/Plumbing ❑ Basement/No "='."aumbing, 6. c y P le # Sinks # # Urinals I s :gailons per 7. Type of water supply: 7County/City ❑ well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 1/N0 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. FR0 QT— I SS IF-r Property Dimensions: G -19 O T WRITE DIRECTIONS(from Mocksville)to PROPERTY: Taz Office PIN•V3 # CLIs�ptr I'15 F T R)�,cD�-�oFT --C Q 1 ` I�� 0-.Au U E1 �d 0 Property Address: Road Name City/Zip_► (I kSy 1 � 1<� 1 T� I If in a Subdivision provide information,as follows: 3 f"N L-o+ n n 1 V Name:N--o �)=� ONE (' Section: r Block: 016 Lot: Date Property Flagged: 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 D vie County Health Department to enter upon above described property located in Davie County and owned by . fI'S And nP)I w5 E4o—n5 to conduct all testing procedures as necessary to determine the site suitability. ATE =f-L q R SIGNATURE Le '�e THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed elines and dimensions, structures, setbacks, and septic locations). Pav ec\ Ped Q Account No. d DCHD(07/98 Invoice No. J l0 tJ �epkv Cano�0 0r\1 VNPre sa►+Ol)e 0 APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERM O U I Davie County Health Department Environmental Health Section SEP 1 8 IM P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL. x DAVI 1. Application/Permit Requested By 1 Mailing Address ` 70 Cs Home Phone !29,F#rf 2 7 BusinQss Phone' 2. Name on Permit if Different than Above 3. Applidation/Permit for: General Evaluation ❑ Septic Tank Installation _ t 4. System to Serve: louse ❑ Mobile Home ❑ Place of Public Assembly w ❑ Business ❑ In Other R El Unknown 5. If house, mobile home:Subdivision �� vRab�Sf tion ZZ 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 i No.of People Served No. of Sinks No.of Commodes No. of Urinals No. of Lavatories No. of Water Coolers i No.of Showers Water Usage Figures 7. Type of water supply: M,-Public 7 ❑ Private ❑ Community 8. Property Dimensions ) /- �,a&k 12,Czu42 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: I �, �pjjti ��,�;�yjy ��/� j� ]�LL !-► G%�%k/ , 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. DAT SIGNATURE 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 DEPARTMENT Environmental Health Section Soil/Site Evaluation `� NAME \r �Si�T►: DATE EVALUATED � -� ( .9S7 ADDRESS J �"nna PROPERTY SIZE I �� X PROPOSED FACIILTY 0144-06 LOCATION OF SITE �0 v ` Q';g-0-b Water Supply: On-Site Well _ Community Public Evaluation By?��p tL_ Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position Sloe % �'— HORIZON I DEPTH Texture group Consistence Structure MineralogX '+ HORIZON II DEPTH Texture group Consistence Structure Mineralogy ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy -HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 9-S RESTRICTIVE HORIZON CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � S EVALUATED BY: LONG-TERMACCEPTANCE RATE: Y'\ OTHER(S) PRESENT: REMARKS: �X4Z 111 d 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-V,---y 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 =====___MEMEMM_::__ MEMO_NOMINEES ____ ■.■.■..■■.■■■■■■.■■■■.■..■■■■■.■IN.IN■ININININ■ MINE ■ ■ INMM ■■■■■■ ■■ ■■■■■■■IN■■M■■e■■M.IN....IN■■■MMIN■■eeM/MM■■ ONE ■ MI MEE EMEMEMEM so ■..■■..■■■...■■■■■■■.■.■■■■■■..■■■■■■..■■■■..■■��■M■IN■Mnt/MEIN■■■ ■■■.■■■.■■■..■.■■■■...■■■■■■.■...■.■■■tIN.ININ.IN■■ MINE■t■/■■■■.■.■ ■■■■■INMM■■■INM■■■IN■■■■■■■..■.■■■■■■■.�■ONE■■I■■■■■■=■■■■■I■■■■■■■■I �::::::::::::E:::.:_::===C. .......■........................�......■H�IN..■.MHIN.IN..E■IN■IN IN■■ .........................■...... ■■■IN.■■■ ■■ ME■■EININININ...a■... 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(0.747 AC.) i' = �� LOT #29 �J• '� ' (0.700 AC.)`v • o /c, LOT eft.0 ``3 4+: `~ 0.789 W -7404 vLOT #31 s LOT 11 (0.796 Ac.) nr (0.695 AC.) r- DRAINAGE I 5.00 _ EASEMEVT 100.00 100.00 100.00 95.00 100.00 6S.Op _ _ ,�4;3 ^CONTROL CONTROL N 88.33'12 N 83.4 '38' W 1 2150 5.15.0 �3,�0 cu CORNER I I CORNER I 00 '� I I I 5 ! 1 I I I I ! I I I LOT 2 I LOT 3 I LOT 4 I LOT 5 LOT 6 I I I I NORTHBROOK — P I I I I PLAT BK. 6 P I LOT 1 ! ! I 1 o AA I I I I I* f pID&Z 10X70 S.E_