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156 Northboork Dr Lot 30 wp F.vd-&'P .a .+.-.., tr, # ' siSrr lira • - J.w•Y. �^ice, ' .. . 3_.; f AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT y✓x�- '» %� �n �,.1 Environmental Health Section PROPERTY INFORMATION: Permidee's P.O.Box 848 Name: F)i..�ws Mocksville,NC 27028 Subdivision Name: Phone#:704-634-8760 r;. Directions to property: Ct�113 TI) fi r. C Section: „LL- Lot: '`��n AUTHORIZATION FOR * �.t(AT- 1)1`3 L-T►l 1( Gt�1 WASTEWATER Tax Office PIN:# -� SYSTEM CONSTRUCTION Road Name: f ip: **NOTE**This Authorization for Wastewater System Construction MUST B ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Nu r should be presented to the Davie County,Building Inspections Office when applying for Building Permits.(In compliance with(Article 11 of G. Chapter 130A,Wastewater Systems,Sectici 1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION AR >/,j AN IS VALID FOR A PERIOD OF FIVE YEARS. ENVIR SPECIIS DAT—EIS ED E AL DAVIE COUNTY HEALTH DEPARTMENT � a 374 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION s.l ce � - Name: Subdivision Name: 1ft8Pbgi4 fM��C?4 Section: Lot: 50 Directions to property: �-��=`1� `�E F IMPROVEMENT P . . tt.�11 f" L-� 1�<'..TI��'I� !r1'� PERMIT Tax Office PIN:#�- - (067 t .r J C:l?.. �' t l ',+•�A C� Road Name: c+ ip: 4Z **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) � f f ***NOTICE***THUS PERMIT IS SUBJECT TO REVOCATION IF SITE OE�k PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIR 1Cfg*A Ati H SPECIALIS SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS— !, #BATHS—?#OCCUPANTS GARBAGE DISPOSAL:Yes oy�o) COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFI #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY CakgY DESIGN WASTEWATER FLOW(GPD) NEW SITE V/ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 1 GAL. PUMP TANKGAL. TRENCH WIDTH ?1, ROCK DEPTH 17 LINEAR FT._23 OTHER ) Tlfl a&)I n O tf)1, G REQUIRED SITE MODIFICATIONS/CONDITIONS: Lj Kcc-� ,t i)K Fa0Js C-- . C -= 10 [7F� t r-v�.(.l '►j IMPROVEMENT PERMIT LAYOUT '?�,svts :> I _ _ S1 N �QA.Jz` **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 SYSTEM INSTALLED BY: ��^' t <ZWIAIA 3 I Jai 1L r—p"m -70 50 B' AUTHORIZATION NO. J ' OPERATION PERMIT B �4&1�& DATE: 17 h Y **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE YSTEM 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. DCHD 05/96(Revised) i r APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC Davie County Health Department Environmental Health Section P,O.Box 848 Mocksville NC 27028 X 0' AR 2 (3 6 75I-5760 f % IN ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCE SE ENTAL HEALTH -� ALL THE REQUIRED INFORMATION ISP OV pAViE COl1NTV 1. Name to be Billed CREWS Contact Person •�EKR!jr C2ewS Mailing Address 40 ( 0L I oa'E "PL8 _ Home Phone /2- 76/9 City/State/Zip /\/G 2702,e Business Phone yyZ-7618 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation Improvement Permit&ATC ❑ Both 4. System to Serve: Vd House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 # Bathrooms 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: /County/City ❑ Well ❑ 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 PLVkTWF THE PROPERTY MUSTBE SUBMITTED WITH THIS APPLICATION. Property Dimensions: a`/J' X lsg-fA /J X /0'p 1 WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: # Sia 0 - 31_ - )l 1 1 HW aye 7.0 TTAa��S Property Address: Road Name I D-Rnmecak DR— 1 1 C,4u0-e w RJ — 7 (RAJ 4epy- un/ city/zip MnGKS V i l 1-JC -z-z6 zz 1 1 yTi�r►�5 Tt� NoR7NBRaot�- 7Zc 1 If in Subdivision provide information,as follows: 1 1 � I►T - SOT on/ r�� r Name: NOAJ-7t13R0or, 1 1 Section: fah i4s -rW C) Lot #: 30 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 Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by R to conduct all testing procedures as necessary to determine the site suitability. DATE 7-Z 3 SIGNATURE Revised DCHD(06-96) ° YOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR "SITE• PLAN. OT 30 - f t z' ol� '3+2pa1� y . r 4"l66VVVV WA64 m6R"l%fmj _Mddw,Jld%dl � Vvl V,/YV IJ.4dLIO .4,VV IVV.IJU A� 00, Alo" - r ti � / f o �. Swa\ \ .Oka 'oe base �r ! � � may/b / � � f��•' � �u` � �� .. . Ilk 1 I +.0 it w�� a NNYNZNZOZ'X14 ,x�►NHtANatNNNNNN tANtAp(giANlhMtA CR MOM �s+�ssta»�sstsstasa:asssa . 1'4PIPIPIfRfR1E�E7Ew, .,�• :''ilk+ � � � � d ! APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department Environmental Health Section SEP 1 8 1995 k P. O. Box 665 Mocksville, NC 27028 r ENVIRONMENTAL DAVIE COU E COU t 1. Application/Permit Requested By Mailing Address Home Phone !29,9#rf 7 Business Phone Y 2. Name on Permit if Different than Above F 3. Application/Permit for: VYGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: q?/House ❑ Mobile Home ❑ Place of Public Assembly I ❑ Business ❑ InduMey 171 Other R ❑ Unknown 3b I' 5. If house, mobile home:Subdivision NO 1-t vR�a�Se n � Lit#�ME F ❑ 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 r 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: 123'Public T. ❑ Private ❑ Community 8. Property Dimensions ) ��b,Yea��-- G tCl�dRL Sewage Disposal Contractor 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: G%ff , ��Vv�{ ��L1�`�Iv i�/�v�/ 'I r. � • /r IVO �/t�� G��i� - . 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 kb_� # C� "• Environmental Health Section Soil/Site Evaluation q q Q NAME DATE EVALUATED ADDRESS PROPERTY SIZE r y f�v PROPOSED FACIILTY �,�OySa LOCATION OF SITE OR�1n tJ�O�� Water Supply: On-Site Well _ Communityy Public v� Evaluation BykAuger Boring Pit V Cut FACTORS 1 2 3 4 Landscape position Slope % -15 HORIZON I DEPTH 4.01 Texture group (ZL- Consistence Fm Structure *1119 1 Mineralogy . t HORIZON II DEPTH 1' Texture groupC, Consistence f Structure P R MineralogyI'. HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS RESTRICTIVE HORIZON SAPROLITE — CLASSIFICATION LONG-TERM ACCEPTANCE RATEI SITE CLASSIFICATION: EVALUATED BY: ` LONG-TERM ACCEPTANCE RATE: ►y OTHER(S) PRESENT: N d 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-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 Mineralocty 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 ■■■■■■..■...■...../......■.■.■...■.......■.....■■■■■■■■■■■ ■M■ ..■ ■.■....■■■■■.■■.a...E■MEM.■..■.■■.■■■■■eeeeMe■■eeeeeeeeeeeeeM■.■e■ .......................................... ........ ............. ■■M.E......MMEE.E.....■..■■■■■.■ ■■■■EMMOM■■■.■M■■■■■■■■■■■■■.■■■ iiiiiiiiiiii°■iiiiiiiiiiiiii�iiiiiiiiiii°iiiiiiiii�iiiii°■iii■�iiiiiiii ■..■..■■■■■■■e■■.■■■■■■...■■■■■...■■e.eeee■■.■ .e.■.eH�e■■eee■■e■ ■■■.■■.■..■■■■........■....■..■■..■■■■■■i�MEN=�NMI■�°=MEN eiiiiiie'sii ■.■■e■M.■.■■■■■■■■.■.■....■■..■■■.■■■■■■ ■■.■■■e...■M■■e.■■.■■■■...■■■e■■MMe■■■eee■e■.e.e ■■eee■eeeeeeeee■ ■■■■..■......■■.■■■■.■..■.■■■.N .■■.■Mee■■■O■■.Mee■■e.■■■.■■■■■■ ■.■.....■■■■.■■■■■■.....■■■■■.■■..■■■..■■■■■■■■fie■■e■!■■■■■■■■■■■■ MOMEMEM ■■.■......■■.■...........■■■■.■■■.■■■Mee■■■■.■■ ■e�■e■■■.■■■■■■■eM■ ��_�°��.■iiii=sii°.°�ieiiiii=i= MIN � .......N■■■■E■■■■■■.■MM■.M..■■M�.■M■■M■Nee■e■.N■■■■■..■..�... .......■........................ ........ ■■ "MM■MMM■M.■M.M■M■ ■■■■..■■■.■eee■■■E■■■H■■M■M■M■■■M■NMM■Oe.■e. 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