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111 Yankee Ln Lot 2 5;;pry. o-, �,,, r:}}.R�. :.. X/ O.. 674 DAVIE COUNTY HEALTH DEPARTMENT, w ys TMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION +�.3a Permittee's P Name: !1 OC1�� Pt - N Subdivision Name: Directions to property: Section: 1 �' Lot: 2- "ROVEMENT PERMIT Tax Office PIN:# k 4) Road Name: o'' �:� Zip: ' U:.y **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 pemut. (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,S ECIALIST DA ISSUED . SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE E INSTALLING THE SYSTEM. . RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS 3 #BATHS_Z_#OCCUPANTS GARBAGE DISPOSAL:Yes or(9 COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No t13axU'r, LOT SIZE I '' TYPE WATER SUPPLY Cno DESIGN WASTEWATER FLOW(GPD)5,9D NEW SITE_ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE �GAL. PUMP TANK - GAL. TRENCH WIDTH .ROCK DEPTH LINEAR FT.' a� p OTHER 07 1`JP—' 1L REQUIRED SITE MODIFICATIONS/CONDITIONS: ' IMPROVEMENT PERMIT LAYOUT . • 'T o %D fc?�''��Z" 40x. -1 F-5 **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 D F INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT C n SY M STALLED BY: �© is �. AUTHORIZATION NO. i 00 OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT SYSTEM DESCRIBED A HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 I 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 E. DCHD 05/%(Revised) - � a✓ �^ s'•4�- •i. -- :cr i' T; ...4.+v. ..y.« y. .'v.� :'SY'•"y, j•.�iA! .Ia :r. .,,� _ .�;R�. AUTHORIZATION NO 16 " Q DAVIE C LINTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION iq Permittee's F' P.O. Box 848 %30 Name. !0 ' Jpf�- Mocksville;NC 27028 Subdivision Name: ,rhone# 336 751=8760 Directions to roperty: '(rel S 'i�." 4�t�� '?t�� Section: Lot: AIJTHORIZATION FOR c C c�Y k� �2^� WASTEWATER Tax Office PI N:# � 1' /��ko /^ r SYSTEM CONSTRUCTION o !bRoad Name. .Zi, dZS _ **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.: (IIn compliance with Article I I pf G.S.Chapter 130A,Vastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION .! "Jt1 7 �j ` IS VALID FOR A PERIOD OF FIVE YEARS. ENVIR MENTAL:HEALTH 9PES90ST DAlt ISSUED APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&AT �t Davie County Health Department Environmental Health Section P.O.Box 848 ` Mocksville,NC 27028 (704) 634-8760 . N ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE NMS' ALLI p THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 6 P 1 LL-MO-N Contact Person �O6�Co� V' Mailing Address PD 00%- -738 Home Phone a94—a-114-1 City/State/Zip C e-im et N c- J-1 o'+ Business Phone 0-�gL�— 2. Name on Permit/ATC if Different than Above '01 Mailing Address !N' VW X� City/Stateop 3. Application For. M Site Evaluation [A Improvement Permit&ATC [ ]Both . 4. System to Serve: [ ]House [ Mobile Home [ ]Business [ j Industry [ ]Other 5. If Residence: #People #Bedrooms-,.i _ #Bathrooms Z ::� 1 ]Dishwasher[ ]Garbage Disposal [ ]Washing Machine [ 1 Basement/Plumbing [ ]Basement/No Plumbing 6. I: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: [4/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**-NXWW OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: DIRECTIONS(from Mocksville)TO PROPERTY: Taut Office PIN: # 5�3� 4-0 43 •�� Property Address: Road lflame 0 City/Zip OCkS U 1 11-e If in Subdivision provide information,ps follows: I QVS Nune: h4 Section: ! Lot#: Vv This.is to certify that the information provided is correct to the best of my knowledge.I understand that any permits)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 ACU.Ci Ardersoh conduct all testing edure necessary to determine the site suitability. DATE �= q SIGNATURE 1 Revisal DCHD(06-96) THIS AREA MAID BE USED FOR bRAWINC YOUR SITE PLAN: �l N Z W4ex-It.-a ZriCt,t��- W ,by / H SS•4!S.� .. Trli'r p'+�o 4 79 Sq TOW �•iP �d4 SQ• C � 293.21' 2775 Erp �= b' S 4 16,05,,W 25.1 � 318.31' ! S Ss 48SS• sw'�m R°tO/w rn `�So,w 336.21' 24.23' N +--_ 31.26'10"W 3W.44- %P 60.44's ` Z � 32.450 FL Tot 263.8 � O � '.._ a POrce/ 65 S 31.26'10"W 288.57• 30735 S; N f -.- " 1 _� �'R '^ 'Sc 2.51. I n�J ig �„' S S 35°24'55"W .14;W225.36' a u tps?e �R t,�a UP S 35• '55"W 142.99 z Sp.t�5� R�►+'134.69' 9e S 27'53'45"W 160.15' J: 1 30• 30' z � 0 PQrcMerry Cel 67 r i(: � t �" Pe a� of A t c1 Cel • �8' 97 685 0 p•B. B99 e a�so,� �, S-R. 1125s+,,. a v_A tv- — Noll, �- 2623 \� w'W.t wy_ U VAN' ""°"(a.e caner per' w "';' as 4%1%,lef-10, C. Bruce Ar?aE IV Coro/, * OW MoCksville Ave De 4e)e— rJ— DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT_._._ Soil/Site Evaluation > , �r APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE 1T0o�Ct' SUBDIVISION �� .��P�,(> ROAD NAME Water Supply: On-Site Well Community Public 1� Evaluation By: Auger Boring Pit ,cam Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence - r 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: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: 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 clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE oiA 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 DCHD(01-90)