152 Peach Farm Trail � yr {r -- N'�ar.;-,�'�eSIK'��.�,� e•',a"t j'r+.�,° �}»g *n`y•M .��w �73?r �+r«�ya tF',y `r x ,. ��.:
at
-A TAGRIZATION NO: "
`' t I,A DAVIE ,COUNTY HEALTH DEPARTMENT
En
ental
Health Section PROPERTY INFORMATION
Permittee'ti��"'/"~ " P.O.Box 848,,
`Name: �/ / � i' ;y„s Mocksville;NC 27028 Subdivision Name:
/ Phone# 336-751-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR r� -
”
WASTEWATER Tax Office PIN:# /� I�Q S
SYSTEM CONSTRUCTION
Road Name � f 'Lip:
**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 I I of G.S.Chapter I30A,Wastewater Systems,Section 1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
.�Tyw ,� .:`'-• w+ �-'.. xy- Grp (':qtr„ ny�. _ ��.._ ' y ,�. ^; � +q.k' - _-� { •..{ ` - _ a
7A DAVIE COUNTY HEALTH.DEPARTMENT
IMPROVEMENAND OPERATION PERMITS PROPERTY INFOYATION
Minittee's r .✓' �,'
-
sNattieaVs Subdivision Name
} -
Directions to property: . ' !/. ; ;,-;i ;: % ✓' Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name .a?F'r'.., r:' .;a •Zip:.
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must.be obtained from this Departmentpriorrto they'
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)
�' ✓, ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER'
ENVIRONMENTAL HEAL SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE,,
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE /P7 # BEDROOMS # BATHS # OCCUPANTS ,= GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS %INDUSTRIAL WASTE: Yes or No
LOT SIZE Rc TYPE WATER SUPPLY �i�le%/ DESIGN WASTEWATER FLOW (GPD) NEW SITE l� , REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE,��GAL. PUMP TANK GAL. TRENCH WIDTH c 741, ROCK DEPTH r � LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"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 l *VjW c
DCHD 05196 (Revised)
zl—c�
APPUCA110N FOR SIZE EVAUTA-UON/IMPROVEMBU PERMIT do ATCFf%A
a
/ >
-)"4 Davie County Health Department
Env/tonmenfal Hea/tfi Se+cffon
P.O. Box 818/210 Hospital Street 10
i� Mockaville, NC 27028
J (336)751-8760
si ITV HEALTH
***IMPORTANT*** THIS APPLICATION CANNOT 8E PROCESSED UNLESS 'ALL TEN—IEQOIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Haase to be Billed � � v Copta ft parson
Mailing Address � j/e Hama Phone �'
3
City/state/LIP v 1C' -
Business Phone
Z. Hams on Persdt/AT'C if Different than Above
Mailing Address City/state/Lip
a. Application For: j Site Evaluati n
a. system to service: House Mobile Home
@'
0 Improvement Permit/ATC If Both
0 Business 0 Industry 0 Other
a. If Re-&.8ZageoDisposal
ple
;Bedrooms �i Bathrooms
ishwasher
Kashin Machineq W16ement/Plmobinq 0 Basement/Ho Pinabinq
6. If Business/Industry/other: Specify type # Pavia / Sinks
l Commodes �_ f Shovers / Urinals i Nater Coolers
._[F FOODSERVICE: if Seats Estimated Water :"a ?gallon per day)
Tp
7. e cf water supply: U County/City Well 0 Community
i
e. Do you anticipate additions or expansions of the facility this system is intended to serve? U Yes No
i
If yes, what type'
***IMPDRTANP** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: k `WRlTK DIRECTIONS (from Mocksville) to PROPERTY:
Tai Office PIN: # e 9�- C� -�1 a� (, 000�)� t,44e e s r <7b l n2 ± -l�
0�
Property Address: Road Nam670 114
City/Zip r 1-�s hU��� ��Gda til S�/^ Dom►
If in a Subdivision provide information, as follows: Le rfi 6'0 G rw, d LX�Yye �D
Name: � I �I U . / o 6w -t � �� �0 1��� }G �'�`�e,��"
L2C� Shut/< ir,��
Section: Block: Lot: Date Property Flagged:
This Is io certify that the information provided is correct to the best of my knowledge. I understand that any permit(:)
Issued hereafter are subject to suspension or revocation, if the site pians or Intended use change, or If the information
submitted in this application is falsified or changed 1, also, understand that I am responsible for all charges incurred from
this app/fcatiFon. I, hereby, give consent to the Authorized Representative or the Davie County Health Department
to enter upon above described property located in Davie County and owned by I it 'ZZ I l'yI tP`
to conduct all testing procedures as necessary to determine the site suitability. 3('V)X
DATE �— I 1 I SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN ude all of the following: Exi d proposed
property lines and dimensions, structures, setbacks, and septic loca ons).
Revised DCHD (07/98)
Account No.
Invoice No. (B L'A
lv-�G l2�
NEWIRON
pLA /
p�CED y
HAZEL L. PREVETTE
p•B. 59 Pg. 511
66 pg. 595
C -o
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5
INCLUDES S.R. 1335 R/W
HAZEL L.
PREVETTE
y
1
• D.B. 59
P9. 511
595
D.B• 66
Pg.
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GARY W
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DAVIE COUNTY HEALTH DEPARTMENT
�l Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME (� �� " DATE EVALUATED
PROPOSED FACILITY / PROPERTY SIZE /
SUBDIVISION ROAD NAME �C/�.r/4,alVIr
Water Supply: On -Site Well . !/ Community Public
Evaluation By: Auger Boring Pit
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Slope %
17
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
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
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: -
REMARKS:
DCHD (01.90)
EVALUATION BY: O Ell/
OTHER(S) PRESENT:
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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
is
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
SC - 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
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 848
MOCKSVILLE, N.C. 27028
336-751-8760
April 19,1999
Mr. James George
1181 Daniels Rd.
Mocksville, N.C. 27028
Re: Site Evaluation/6 Acres/Edwards Rd.
Tax PIN # 4890-86-5105
Dear Mr. George:
As requested, a representative from this office visited the aforementioned site on
April 14,1999. Based on the information provided on the Application for Site Evaluation
and after the evaluation was completed, the site was found to be provisionally suitable
for the installation of an on-site sewage disposal system.
Before a representative from this office can issue an Improvement Permit,
Authorization to Construct you must contact this office and set up a time to meet an
Environmental Health Specialist on the site.
If you have any questions, feel free to contact this office at 336-751-8760.
Sincerely,
0%
Robert B. Hall, Jr., R.S.
Environmental Health Section