298 Ijames Church Rd Lot 1;+,4 'v$3+i..� } bwY7y-r i}''''i i� } .. +rt:3 ,`t�{v ;4!` j j +:.: t , _ - .... µ A S '-y'""•.�r;, +h.?:r:
*A 'l?(fZATION NO: .U 8 9 9 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O.Box 848 '
Pernt�ttee { ! � -1�� Y117►`� N . (�
dame•=-- � Mocksville,NC 27028 Subdivision Name: .Nast. b01K
/ Phone#:704-634-8760 t
Directions to property: (nb N �.,�a�. Section: Lot: f
1 AUTHORIZATION FOR y'
a. -
\ss` ow. .�." 0+n. ' ► WASTEWATER Tax Office PIN:# -
T— SYSTEM CONSTRUCTION
Road Name AZip:
NOTE This Authorization for Wastewater System Construction ISSUED b the Davie County
**NOTE** y y ty Environmental Health Section prior
to issuance of any Building Permits.This,Form/Authonzation 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
a- 1 IS VALID FOR A PERIOD OF FIVE YEARS. „
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED r
F`1'+ri�T �� 'y.t ��i .�us�w—p, +�• cy,..y:.{r�.-h""ti A.w+.N-l*r-ir'`4(''cv �.xx'�v- }y r�F`D"' 1.t ::a�.. ,,�?7',.'a•.�xa..-Fa,-r wi n..;�.�w .:.i.i��,a•-ro'�,,:;„, ��.,-;���,.r,,�•' 'rij r+s}t. , ..,. ��
DAvint COUNTY HEALTH DEPARTMENT . ' f'
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name: t' �_ fie. Ski
Subdivision Name: 6R.)A
Directions to property: i ,'`) tj �r', - �° Section: Lot:
IMPROVEMENT
le
PERMff Tax Office PIN: - -
., e S..z�, '} z.. Road Name _ tti -, `*` ,Zip:,fj �.}
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system:Ari
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.
f (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 WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT.BEFORE
INSTALLING THE SYSTEM. '
RESIDENTIAL SPECIFICATION:BUILDING TYPE 0\Y_ '#BEDROOMS_-5 #BATHS '�. #OCCUPANTS '"" GARBAGE DISPOSAL a or No
- r
COMMERCIAL SPECIFICATION: FACILITY TYPE .#PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZ45O X 1`TYPE WATER SUPPLY 10 DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZF!600 GAL. PUMP TAN$ GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PE IT LAYO
kill
ao�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY h<H 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
SY M INSTALLED BY: A1S1�1a�
J
e �o,
log,
ac,
AUTHORIZATION NO!�% \5 OPERATION PERMIT BY: DATE: +
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM 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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME:
DCHD 05/96(Revised) 3
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville,NC 27028 '
M (704) 634-8760
� I
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed yl MP Eajene- ,5hy1e,- Contact Person
Mailing Address I V.2 61 vlel,/W Home Phone
City/State/Zip ,I/e, a7o.7.1 Business Phone 9W � s-
2. Name on Permit/ATC if Different than Above
j Mailing Address as 6X 01C.- kela City/State/Zip ��%/
3. Application For: [ ]Site Evaluation [,xImprovement Permit&ATC [14/Both
4. System to Serve: [O'House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People #Bedrooms--3 #Bathrooms [•113ishwasher[Garbage Disposal
[k4-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 [L4'
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***AIMOF THE PROPERTY MUST BE
y SUBMITTED WITH 1HIS APPLICATION.
Property Dimensions: t /5'4 X 360 ;WRITE DIRECTIONS(from ocksville)TO PROPERTY:
Tax Office PIN: # 5.0.7o - 3'a - i s�� l Nor Id� O&e
r Property Address: Road Name AbrfAloroot fir- rz rn;le k.."
City/Zip 1770ceSville Q>.C. A 1114 /cVZ 1 4
If in Subdivision provide information,as follows:
Name
Section: Lot#:
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 ; ✓)A Eojege tto conduct all testing procedures as necessary to determine the site suitability.
DATE 1a -6 —yp 7 SIGNATURE
Revised DCHD(06-96)
THIS AREA MAY $E USED FOR DRAWINC7 YOUR SITE PLAN:
I � �
_32— —7
Lai
Co A�
s 83.43�3Q• lf. 100, 00 ' 100. 00 ' 100. 00 '
I so. oQ , 4
I"C-3
Xv
CS COo o i '" � •r
c; cu
Ocs ® ® U0
� N 0 � M � �
La 1.033 Ac o N o 0. 795 Ac ' 0. 807 Ac '�' 0.826 Ac
It' 16 a w � f ,;
W W i
n W � m W �
HARVEY •
L. ADAMS �; cu • � •
D.8. 102 PG. 795
0.8. 93 PG. 317
f Zoned RA 8 R-20 e;na:on • CID ^ Z ... 0�
o :n IA j` : o
• ( 10' x70 ) t0 • �+ ow !� •
Z SIGHT EASEMENT f , x W Z o p
20' 6" R�
Pavd
"~-- ---- — b N
-_
O
s0. 00 ' N 60 o - o
RQAD � `� • 01 100 Ira 0 0
130? --- o_
--.._ oti; ~'_ N 83.48'38• . 00 -- N 100. 00 • —
`~– 502. 27 ti 92, 26 • — ti .
1. 3 'so
91 R LEE
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMITd
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 ENVIRONMENTAL HEALTH
g
DAVIE COUNTY-
1. Application/Permit
OUNTY1.:Application/Permit Requested By
Mailing Address
Home Phone_ 9/D- g 9 72 Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: (t216eneral Evaluation ❑ Septic Tank Installation
4. System to Serve: louse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No. of Bathrooms _ ❑ Dishwasher
Dwelling Dimensions /2,0 ❑ 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: Public ❑ Private ❑ Community
8. Property Dimensions aA4,P7 a,-Al. 1 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? f'fes El No
If yes, what type? c. p-r
'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: #&iC�!itV GPiYfi 6
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.
ht
DA E 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 representati of the Davie Cou Health Department to enter upon above d s 1b
property located in Davie County and owned by
to conduct all testing procedures as necessary to d e mine said site's suitability f ground absorption 91wage treatment
and disposal system.OATE SIGNATURE
DCHD(12.90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED -7 -0- 9,3-
ADDRESS �.'tc�Q PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE �.ta �fl
oe
Water Supply: On-Site Well _ Community Public
Evaluation By:�t.�Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe Z
HORIZON I DEPTH '
Texture group C, L �-
Consistence F
Structure C
MineralogX
HORIZON II DEPTH Z' :L"
Texture groupC
Consistence
Structure k `F
Mineralogy V.
HORIZON III DEPTH
Texture group '
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE --
CLASSIFICATION $ ,S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY:
LONG-TERM ACCEPTANCE
RAT 1 OTHERS) PRESENT:
REMARKS: ' "a
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
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