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2431 Hwy 601N Lot 2
AUTHORIZATION NO: Q 5 7 2 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFQRMATION Permittee's a P.O.Box 848 Name: ! ��Y Mocksville,NC 27028 'Subdivision Name: /©/�,j Phone#:704-634-8760 Directions to property: ` Section: Lot: AUTHORIZATION FORWASTEWATER Q' , , SYSTEM CONSTRUCTION Tax Office PIN:# - 7lt T - 44o#� - awl 6QI/ zip: I- Road Name: -� Zip: **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) I ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENfAL HEALTH SPECIALIST DATE ISSUED ;, x - DAVIE COUNTY HEALTH DEPARTMENT { IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Narr1 .' ✓ Subdivision Name: r Directions to property: `t // Section: , Lot: IMPROVEMENT PERMIT Tax Office PIN:#A,�?o l Road Name >e E3�lY• Zip: ,r jl Cbl **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 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 #BEDROOMS 7 #BATHS Z_#OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY�( DESIGN WASTEWATER FLOW(GPD) :F0 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEDDD GAL. PUMP TANK/Dd�GAL. TRENCH WIDTH ROCK DEPTH ,' "LINEAR FT.ZrW OTHER ��/� REQUIRED SITE MODIFICATIONS/CONDITIONS: ' IMPROVEMENT PERMIT LAYOUT :a **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)634-8760. OPERATION PERMIT SYSTEM INSTALLED BY: `C' wJa� JJSt�S� LE h� a . t7 *Qw q Tr Qoj I AUTHORIZATION NO.__S1 I 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) /. APPLICATION FOR SITE EVALUATION/IMPROVEMENT' J ' r G�jj Davie County Health Department Environmental Health Section D I P.O.Box 848 OCT 2 1 (�} Mocksville,NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PRO SSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. a 1. Name to be BilledWn"') } avick Contact Person Mailing Address A 03 m�`\'A`� r I, J Home Phone 93;7e— City/State/Zip 3;7eCity/State/Zip ACl JA') Lp A/C_ C� 70& Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: (n Site Evaluation e Improvement Permit&ATC 0 Both 4. System to Serve: ❑ House ZMobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People `P # Bedrooms Lr # Bathrooms Jd Dishwasher ❑ Garbage Disposal 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: o 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? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE f SUBMITTED WITH THIS APPLICATION. Property Dimensions: / / 6 1 WRITE DIRECTIONS(from Mocksville)TO PROPERTY. Tax Office PIN: # ZiaDO ` - - U Property Address: Road Name o� u� �o D` 4 1 city/zip Mu �1�\Ve W•C _ Q O 1 If in Subdivision provide information,as follows: 1 1 . Name: Al a 1 Section: Lot #: 1 1 1 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 determi /the site suitability. DATE V SIGNATURE /-Y 2,.,'/" A. Revised DCHD(06-96) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. A lication/Permit Re uested B Qi1�' cvv ✓i. . PP q Y Mailing Address •- Home Phone r1—/E Business Phone "2 .`Name on Permit if Different than Above 15 `3. Application foe: 0 General Evaluation ❑Septic Tank Installation Permit ,4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown L 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing i 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: ZPublic ❑ Private ❑ Community i 8. Property Dimensions 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. i Directions to Property: PROPERTY INFORMATION REQUIRED: Tax Office PIN: # Q.�� G�–• O PROPERTY ADDRESS, as follows: GAJ(/ Road Name: 4 Ql n � �$ City: Woe k2 Vdle- � SUBMIT A PLAT WITH THIS APPLICATION. l � 0 Revisions effective October 1 , 1995. �.? 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 incurfrom this application'./ ✓`� t'. DATE SIGNATORE 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: I` 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 i to•conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and and disposal system. S DATE SIGNATURE r DCHD(1/93) DAVIE COUNTY HEALTH DEPARTMENT • - Environmental Health Section -�,� ySoil/Site Evaluation NAME l/i7! 01e.' / Zoe C' DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE 1 V Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring I/ Pit Cut FACTORS 1 2 3 4 Landscape position IL Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH r f Texture group Consistence Structure /F R- T 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 R.ATEJ I y / SITE CLASSIFICATION: EVALUATED BY: z& ` 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 ;lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vn.-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 Mineralomy 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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