117 Caravan Lane Lot 4 .::-r,;� ., .:.:..-.,,:...,;,y .,; ,..,..sr.....�:�..._..�.✓,ti^�=- ..ty, -c:¢,..�.. ..r':. Jz:�a,.r..s+r --�. .. ,y.a.,-,w �;:v>�^G:;:as.:� ,. "Q ,. .3ti�t;'�•,w4f-...f'P� .+NJ'�i'f t
AUTHORIZATION NO: 0 9 A DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFOR ATION
Permittee'sf� P.O.Box 848
Name: f t Mocksville,NC 27028 Subdivision Name:
j ,/� J Phone# 336-751-8760
!
Directions to property:` //7 G f71/4 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#J,,rzo g7�
SYSTEM CONSTRUCTION
Road Name: Cjj&wa_ Le,!6 zip: Z ZoZP
**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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
f ; ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST D TE ISSUED
n' -y • y T -ter. „ ,....,:.. rr,r,f ..sv..� •�:s4 ,,, a_ i.
w .p DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITSP �' R INFORMATION
PermitCee n
Name: ' ' `irSubdivision Name: R ' f''a�t k
Directions to property: 111 � : l /• Section: ot:jj
IMPROVEMENTf f t, C t,
PERMff Tax Office PIN:#��
Road Name: (_�t. Zip: Z 7oZJ-
**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 I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE***THIS PERMrr IS SUBJECT TO REVOCATION IF SITE
J r'-'. ,1` _2� ± f' PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST D, TE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE . #BEDROOMS--? #BATHS _#OCCUPANTS �'GARBAGE DISPOSAL:Yes or No a
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE • REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH S151 ROCK DEPTHS 7 LINEAR FT.9;
OTHER M
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER* *RISER(S) IF 611 BELOW FINISHED GRADE*
C
17,4417
Wig
v to
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM,
BETWEEN 8:30 M7
9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(XX) 47WX
(336)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. 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 NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised) .
0
AUTHORIZATION NO: Q 8 9 3 ' DAVIE COUNTY HEALTH DEPARTMENT
t Environmental Health Section PROPERTY INFORMATION
a
:tee's P.O.Box
Name: - � ��.,,;A�'1A*"� Mocksville,NC 27028 Subdivision Name: .�
Phone#:704-634-8760
Directions to property: x"'49! Section: Lot: r
AUTHORIZATION FOR j�
WASTEWATER Tax Office PIN:#. Ad "7 , - ,L d
SYSTEM CONSTRUCTION
Road Name: da ea va)'I zip: (a 6
**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 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
Ir ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
, , ✓ r IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALIfi SPECIALIST DATE ISSUED
r�.,iry Y -g•y.+-.,..•��s r . ..a`a �- ✓ -`;"'l v-vd,.'F:.y�...k \I`y, �':/�•v•':e�'. '-'. � " i ,. Y: .. .. i 4'"h v„•, yt
�A9A DAVIE COUNTY HEALTH DEPARTMENT L.
} IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittees. A� e
Name: ';,.},�.�*'' -'�wx, tt•e, - Subdivision N rne: �'eco pr41l e
Directions to property:
-'M ,�r, ,. I •” Section: r. Lot:
IMPROVEMENTS
PERMIT Tax Office PIN:#iG
Road Name: <4,,g,,,;._ !.— Zip: Z 7o4 P
**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
constructionrnstallation 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 HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE 44, Ig #BEDROOMS #BATHS .:?- #OCCUPANTS GARBAGE DISPOSAL:Yesor No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ' DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER J,t41// A14, 1�'i"�'"tir
rf
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT �,A I I} 1 Fl_�I 1T FILTERtt°+ li►i�alrlltS) I . 6' BELOW FIHISMI) GRADE*
. APa
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTENC
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS('iWM41 AU.X
(336)751-6760
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. 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 TREATMENTAND 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)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION r
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
�D T , /C
NAME y " PHONE NUMBER r
ADDRESS_ _ J1 7 / �i1,4y,-h✓ N` y-e, SUBDIVISION NAME �[tr� Arl e-k
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED 7NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED J r_
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED AO INFORMATION TAKEN BYE'
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93 f X097
/�iN 0G9� -
y •�o
DAVIE COUNTY HEALTH DEPARTMENT
.ik r
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permite't;� . r
° Name: "". ra41� Subdivision Name: l
Directions to property!' 415,01 Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#� �
Road Name °t .0 )1 Zip:
**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]-l:of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and I? Sy�ferns)
7t's
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r r ;; /'x'7: .. ,y_ ✓` < - , PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEAL1fi SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS_ Z_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE o ' 1'"e TYPE WATER SUPPLY L-'e4) DESIGN WASTEWATER FLOW(GPD) Gy NEW SITE I- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZ&�LO GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH /Q LINEAR FT.an /
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
1�
**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)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
7� ls°�3
y'
4D
AUTHORIZATION NO. 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 J/
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05,96(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &ATC
` Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760
t
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed
c-1,A - V Contact Person X10
Mailing Address Home Phon� O C�'wi�g 71
City/State/Zip !/ ' Business Phone 5�944
2. Name on PermitIATC if Different.than Above
Mailing Address City/State/Zip
3. Application For: JSite Evaluation [Improvement Permit&ATC [ ]Both
4. System to Serve: [ ]House [t.}'Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People _ #Bedrooms 3 _ #Bathrooms g [t,]&hwasher[ ]Garbage Disposal
&J*ashing 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: k/County/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes LL. d o
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***XVLX C'OF THE PROPERTY MUST BE
lSUBMITTED WITHrAPPLICATION.
Property Dimensions: t ate, w � �� WRITE DIRECTIONS(fromksville)TO PROPERTY:
Tax Office PIN: # S - _- 8yyD 4
Property Address: Road Name ,! , 5
City/Zip
If in Subdivision provide info ation,as follows:
Name: �'�
Ales
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 ofth��e,�.��Davie County Health epartm nt,to enter upon above described property located in Davie County and owned
byC/� a t c% ct all testing p;oqdures as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD(06-96)
THIS AREA MAY $E USED FOR DRAWING YOUR 51TE PLAN:
r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
10*1
• Davie County Health Department
t Environmental Health Section /
P. O. Box 665
Mocksville, NC 27028
1:',-Application/Permit Requested By �4� ✓v G-��
s Mailing Address �� Home Phone
' y9
t i
Business Phone
:2 .Name on Permit if Different than Above
3;Application for: )QGeneral Evaluation a Septic Tank Installation Permit
r
4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Othpr ❑ Unknown
L
5 If house, mobile home: Subdivision �!� !' / � Section Z 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: Public ❑ Private ❑ Community
.8. Property Dimensions O-Z � 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 from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
r.
PROPERTY INFORMATION REQUIRED:
Directions to Property:
Tax Off i ce PIN: # 0 !K=110
PROPERTY ADDRESS, as follows:
ZG�z4 Road Name: Q
City. '
su / k
l
S
��` SUBMIT A PLAT WITH THIS APPLICATION.
p Revisions effective October 1 , 1995.
1 This is to certify that the information provided is correct to the best of m knowledge, and I understand I am responsible for all charges
1 incurred from this application.
DATE SIGNATVRE
r:
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 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:
(`.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.
s
DATE SIGNATURE
b6HD'(1/93) r
r��
f �
4` DAVIE COUNTY HEALTH DEPARTMENT
t Environmental Health Section
Soil/Site Evaluation
��✓ �7t' D DATE EVALUATED
NAME ��� �i'G?r ,r / l%�(
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position 4 L
Sloe R G
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH p/
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 S
LONG-TERM ACCEPTANCE RATE ,
SITE CLASSIFICATION: EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: > OTHER(S) P SENT-
REMARKS: --�1 - D GL ✓ >`
L GEN
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-Vl::-y friable FR-Friable FI-Firth 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
Mineralog
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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GLENN' M. FOSTER et. al may. I ( e 3�� �ao�
89-117 `�� { �, A.•
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EDffH BOGER
NOTE; IRONS AT CORNERS I °'�a r.. { o' \ 66-52
,. FLOYD L DEWALT. \
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Sections
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001423 Tax PIN/EH M 582044-8440
Billed To: Aaron Waller Subdivision Info: LJ t `�—�� ��`e ? -�C_4
Reference Name: Location/Address: 117 Caravan Lane-27028
Proposed Facility: Residence Property Size: 2.15 acres
ATC Number: 2592
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People #Bedrooms #Baths _
Dishwasher Garbage Disposal: ❑ Washing Machin . Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial
Waste: ❑
Lot Size [� ��fype Water Supply� Design Wastewater Flow(GPD)� Site: New to Repair❑
System Specifications: Tank Size/,�&GAL. Pump Tank GAL. Trench Width 2 Rock Depth Linear Ft loll
Other:
Required Site ModificatKs/Cond!Ros,:
IMPROVEMENT/OP ATiON P M UT- APPR VED EFFLUENT FILTER RISER(S)IF 6 L°BELOW
FINISHED GRADE. *** CE: Contact a representati of the Davie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or @ p p.m.on the day of installation. Telephone#is(336)751-8760.****
STAY �lopOfV, ��°
%
�v/vPhi �`�'�e
L/&lee e�Gi� 5 Ij •s 1�6� e
W'l 1l 401 he ��p1•dl
Environmental Health Specialist's Signature: Date: l0 4
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street.
Mocksville,NC 27028
(336)751-8760
Account #: 990001423 Tax PIN/EH#: 582044-8440
Billed To: Aaron Waller Subdivision Info: Lt y.. Qe I�
Reference Name: Location/Address: 117 Caravan Lane-27028
Proposed Facility: Residence Property Size: . 2.15 acres
ATC Number. 2592
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA ZRUCTION IS VAI FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: . Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
�1
� e,
r '�
C
Septic System Installed By:,) 4 2/)17
Environmental Health Specialist's Signature: /VcyL� Date: —1 —
DCHD 05/99(Revised)
APPLICATION FOR SIZE EVALUATION/IMPROVEMENT PERMIT A ATC � � � a vW
• ~ R r " Davie CountyHealth Department D
Enuftnmentnl Hen/dt Secti'On SEP 2 6 2000
P.O. Bos 949/210 Hospital Street
Mooksville, IHC 27029
(336)751-8760 .
***IJVCRTANZ*** THIS APPLICATION CEO= Ata PROCQSS= MMISS AM THS RZQUIRaD
X ORMIITION 18 PROVIDW. Refer to the IlUUMa 2100 BU=T= for :instructions. /
1. Hams to be Billedh, Contac! Dessau 1_RJI i�Yl 1.1 � l
waiit.ag !dare.. 14 '7 r'r A r'r,.,!/n ri /„4:2 Ross phone
city/state/asp MT0r [�r� !1 P Ylr 7{ 9 swiness whoneg�gG
2. :tams on permit/ASC It Different than Above Home—
Hailing
omefailing Address Cit:/stats/sip
3. Application tor: D Bits (valuation 0 Improvement Permit/ATC GJ-90-th
a. system to services O Hones W"M Lle Homs 0 Business 0 Industry 13 other
s. It: Ptesidence: f People i Bedrooms ! Bathrooms
O Dishwasher O Gasbags Disposal a-Mobimg VaddAft O aasemant/Olusbing O aasement/tto Plumbing +
6. 29 fusiness/tadustsY/othsri speoilY type I people f Sinks I
I Casmodss f showers I urinals t Water Coolers
It 1=82mcs: # Seats estimated Water Usage (gallons par day)
7. Type of water supply: County/City 0 Well 0 Community
e. Do you anticipate additions or expansions of the faeWty this system Is Intended to serve? 0 Ya 971
U yes,what type?
***IMPORTANT"**CUEtM MUST CDMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BEIAW. Either s PLAT orSITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: J Rc re WRITE DIRECTIONS(from Mocksvlile)to PROPERTY:
Tax OMee PIN: a� �q g yi-10 61
Property Address: Road NameIrnnn� OCA l'1 �C.�K?��
Citylzip ' ;P�f-� 2 in res n� 1�/ 1.��(•J�1�
If in a Subdivision provide Infbrmstlon,as follows: c, Le. kte A/'ill d
u {
Name:
p 1
Sectio: Block: Lot: Date Property Flagged: `7 �t P-00
-_
This Is to certify that the lnfbrmadon provided Is correct to the but of my knowledge. I understand that any permits)
lamed hereafter are subject to suspension or revocation,if the site plans or intended ase charge,or If the information
submitted in this application Is blsitied or changed I,also,understand that I ant responsible for all chages incurred frons
this application. I,hereby,give consent to the Authorized Representative of the Devi CountyHealth Department
to enter upon above described property located In Davie County and owned by - (in
to conduct all testing procedure as necessary to determine the site soltabWty.
DATE '�-c?-6 -O G SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, tructrres, setbacks, and septic locations).
6Site Revisit Charge
St�/I
r%rn
Date(s):
Client Notillation rate:
1EHS:
(,�JC1ll2(� Account No. /
It'sed 19 ) Invoice No.
5
J C9
. r
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001423 Tax PIN/EH#: 5820-44-8440
Billed To: Aaron Waller Subdivision Info:
Reference Name: Location/Address: Caravan Lane-27028
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ./ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence i
Structure `/ &
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE I
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
�/1 r i
REMARKS: ("/460 1' mast J e F'e4""l �' ��//h % o�
LEGEND
Landscape Position ww(/"-2
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
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
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 05/99(Revised)
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ENERGYUNITED ELECTRIC MEMBERSHIP CORPORATION
I Aaron f(ei 4-h Wa I l er have requested EnergyUnited Electric
Membership Corporation grant me permission to locate my septic tank and lines extend onto the
EnergyUnited transmission right-of-way as recorded in my deed I fully understand that
EnergyUnited may need to use this right-of-way to maintain their power lines at any given time. I
also understand that I must assume full responsibility for any damage that might occur to my tank
or lines due to their right-of-way. I also must assume the understanding that EnergyUnited may
leave tracks on this right-of-way that they cannot be responsible for.
I A ar on Ke i�h Wakk" also know that when I sign this form I
understand that EnergyUnited EMC is not liable for any damage that might occur on this right-of-
way.
Signed By c Property Owner
Date
STATE OF NORTH CAROLINA,COUNTY OF I JA V1 t
1, K At en ( ler a Notary Public for 1016—
County,
016—
County,State of North Carolina,do hereby certify that (i 4 ro n \Ae 1 y WAV-t r
Personally appeared before me this day and acknowledged the due execution of the foregoing
instrument.
Witness my hand and official seal,this�_day of ()C-4-pbe—
My commission expires 2 12- - Z 003
A�J� R -
otary Public