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179 Northbrook Dr Lot 16 a�a y84. `•, r r � r' ,r]kn.rw...ea ' t �. - .♦-+1.' O. 'AUTHORIZATION No; 164 9 DAVIE C DUNTY HEALTH DEPARTMENT ti Environmental Health Section PROPERTY INFORMATION , Permtttde'c s, P.O.Box 848' Subdivision Name: Name:,- Mocksville,NC 27028" Subd �� Phone# 336-751-8760 Directions to property: Section: Lot: AUTHORIZATION FOR t 1��r1)I�r� t' WASTEWATER Tax Office PIN:# 20 J � � SYSTEM CONSTRUCTION Road Name: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior . to issuance of any,Building-Permits. Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance w`th Article I 1 of G.S.Chapter 130A,Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE*** IS VALID FOR A PERIOD OF FIVE YEARS. ON.• " �� NOTICE THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION , ENVIRO E ALTH S E ST DAYE ISS ED + a: Vii• ���r O 1649- DAVIE COUNTY HEALTH DEPARTMENT ~ w IMPRO17EMENT AND OPERATION PERMITS -,"PROPERTY INFORMATION t ,..,Pertnittbes' ` c Name-" V I'�t,�� Subdivision Name; 06ATP10 0 V Directionsto•property:' ` c) 0 l() Section: Lot: 3 4 IMPROVEMENT .g PERMIT , .Tax Office PIN:# Road Name: `�"i"`' p ,. +D **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 '_constniction/mstallation 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 WAS'T'EWATER ENVIRdNMENTAC H ALTH SPE AI:IST DA ISS ED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE .., INSTALLING THE SYSTEM.' RESIDENTIAL SPECIFICATION:BU (�U • '. _.3 , BUILDING TYPE #BEDROOMS #BATHS 7— #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE'OO+x4Z/TYPE WATER SUPPLY C60d i' � ' DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE�GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH a LINEAR FT. OTHER �I S'�►21�1�1�� /"� x(:'S REQUIRED SITE MODIFICATIONS/CONDITIONS: ItJS T/ /0 d �y"`' '�' `0 or-r ��U`' `kjG ���T SJtf A4� PROVEMENT PERMIT LOUT r r AVO I D d S _ � s o N **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 ,, C 0 SYSTEM INSTALLED BY: � 70 LO H066 d �o Y 7D� 7p iX3�"�i St'•, AUTHORIZATION NO. /A OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S DESCRIBED ABOVE HAS BEEN INSTALLED INCOMPLIANCE WITH ARTICLE I 1 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) �t� cad � APPUCATION FOR SITE EVAWATION/IMPROVEMENT PERMIT Davie County Health Department 5 ' Environmenfal Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 F `'? . ++r(."•OWENTAI HDdili (336)751-8760 D COU ***ZHPORTANT*** THIS APPLICATION CAM10r BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION I3 PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be BillContact Person Oii Mailing Address 1 ,2gp x 22'4 soma Phone-73-y-3 85"4 `/ 9 ?.6-/3 City/state/ZIP 4d OC/-CSU/1[/,o ,/(/:e i 7d g Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/state/zip 3. Application For: U Site Evaluation Improvement Permit/ATC 0 Both 4. System to service: 0( House 0 Mobile Home 0 Business 0 Industry 0 Other 5. If Residence: # People # Bedrooms 7 # Bathrooms , _ Dishwasher 0 Garbage Disposal washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. • If Business/Industry/Other: Specify type # People # sinks # Commodes # showers # urinals # water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ly County/City ❑ well 0 Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes NNo If yes,what type.' ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUB11117TED by the client with THIS APPLICATION. Property Dimensions: lD D a )�; X l?i-!5rX 4L J1 to WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 0--3 - 5"1l�o a r oo//) �p�/ ,oV, Property Address: Road Name 197 Nalelli 6Rooi('b,r !�rJ /yo,'lP 74 Ala' City/Zip,/1'�ksu r'Vp/I(e. ;??O-)S If in a Subdivision provide information,as follows: L©� Name: 41&R4ti hROok p Section: R_ Block: Lot: 4_ Date Property Flagged: / S 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 to conduct all testing procedures as necessary to determine the site suitability. r DATE„g�-- �� q � SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. Revised DCHD(07/98) Invoice No. i jiy. -.1 e ��J' �j.j: �'.vi.�`.?1•-.+ � �,J'Y k,�' ,}I+i�:S �r 1 'P } W; �z: �� a Y + '�s� `�.'�y ,r��e'.�'�X�,`�'.,n�i�j�kp'�:,r��;.rV a,tt'aji�:�•�'L.°'sae#w�rte'�sr`;x� ~tai'�:�-q tf.�!:'Y <,��. '� 1'.� ;�{ � a4. .ems V y.'..',1+.�°^ry tJ}r'15 ) S Ty1 � r '� r' �� f •rr�•:,•- S.?• ti;;�'• dF.' !1 2K� - `!� '� i f � ` , , •'} AL1 �.`= t ,,.?r- -'�. _�.� ir.�'�lfi 41•l .�'�i1' s?. ..c � f -7 � s r _J l' l vhf a i 1• _ � � r..i, •. r� ,�' . Jv r .. } .7 ✓ 1 1 }�a�l, 'r �. i t • IK�Gy� -��t sf'S�:,1 erra 1. � J L/tT' • LOr 017 � :.. � � do k LOT Lff #1 b► +, `� ,��LOr 021 fes; (0.7W Uff � W #13 t ` (0.7= AM) /, Uff #12 (awt AM) ' AM) / LOT LOT #28 (0.7N "c.) LOT #27 Lar #26 LUr / (&no#3,1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM h/ Davie County Health Department Environmental Health Section SEP 1 8 1995 P. 0. Box 665 Mocksville, NC 27028 ENVIRONMENTAL DAVI • pmt 1. Application/Permit Requested By &44 ✓y�� Mailing Address Home Phone !?9,F#7 1 7 Business Phone 2. Name on Permit if Different than Above 3. Applidation/Permit for: P/General Evaluation ❑ Septic Tank Installation 4. System to Serve: louse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ InOuatry El Other R ❑ Unknown 5. If house, mobile home: Subdivision I � vRaa`�SFm 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: 123"Public 7. ❑ Private ❑ Community 8. Property Dimensions 1 12-A&Z a k 13XZZ"L 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: a �, a4L (� a yty� �/G l/ Ra,9 L t- avu 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. DATff 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 DEPARTMENTD� 1 Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED 10 - - (b -99 ADDRESS p• PROPERTY SIZE loo LI LA9 I PROPOSED FACIILTY V\ LOCATION OF SITE N oRth gpa Water Supply: On-Site Well _ Community Public Evaluation By:( £U--Auger Boring Pit Cut FACTORS 1 12 3 4 Landscape position S Slope HORIZON I DEPTH t' Texture group Consistence 'Structure Mineralogy '1 HORIZON II DEPTH Texture groupC Consistence Structure Mineralogy1: 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: S EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: A)o NP REMARKS: \%"\ G.crC -� NN 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 ■.■■■■■■■.■■.■■...■■■■■■■■■■■■■■■■■■■.■...■........■■■■.■■ ■E■ ■.■ ■■.R■■■■■■■O■■■■■■■■■■■■■■■■■..■ R■■■■■■■O■■N■■■■N.NNEE.EO■■■NEON mCComCCCmmoomonnCCCCCCCCCCCCCmmmoomC�■m000CCCCMIN CCCCCCC000CCCCoom EEO■.■■■■■N■■■.■■E.■■■■..OE.O.00.E■EEO■■EON■■.■.CC'C■ C■HCE..N.■■CC■■ ■■.■..■E000O■■■..■■■■■■■■.E..■N.■.OEOON■O■■■.■.■ NNE■■■■■.■.EE■■■ ■..■■■■■■.■■■■■■.■■■■■■■.■■O■■■ ■■■■■■EHEO■NN■■■■NN■ONO■■■O■■■■ ■■■■■■■■.■■■■■■■■.■■■■■■■■■■.■■■■■.■EO■■■■■.■■■o■o■NE■■EHE■■.SEE ■ ■..■■■■.■■■■OE■■■■■■■■■■NO■■■■■■■■■■■■EOO■■■■■■ ■ HONE■E■■■OOEN■■■ CCCCCCCCCC�:CCCCCCCCCCCCCCCCCC':CCCCCCCCCCEM mmmoCCEmE■NE■C■E=N mom ■o■ .........................■.■.... ■■O■E■■■ ■■ MEN■■E■■■■■ONO.■E■ mmonmmomnmmmmmmmnnnnn:.'CCCCCCCCCCC:CCCCCCCCCC■■=mmmomCm�mommmm�o ■■■■O■■■NO■■■■■■■■■■■■■■■■■...■.■■■■■■■■O■■H■■■ IMPAIRER ■E■E■■ ■ ■■OO■.■■■■DOE.N■■■■■■■.■■O■OO■■■■NOON■eO■■.E.■■■� ■NES mNH.■■E■.■ mmmnmmmmmmmmmmmmmmmnmm:■■CCCCCCCCCCCCCCCCCCCCCCCC. m'.mmm.NE CCCCCCCC ■■.N■■■O■■■■■■■OONO■■OO■■EO■EN■■ RE■EN.■O■■E■oO■■NON■Em■■■EEEE■ ■ONE CCCCCCCCCCCCC■"■CCCCCCCCCCCCCCCCCCC"ONE CENE■Cm"'CM CCCCCCC' ■.■■■■..NN■■■E■E.C■■E■muu■■■E■mC■ _. 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