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257 Sain Rd Lot 2 'r1 i�tJTH�QRIZA �iC3N NO. '� DAVIE COUNTY HEALTH DEPARTMENT °{ Rte' Environmental Health Section PROPERTY INFORMATION �B Perms 64 s'-'-' P.O:Box 848 Name;, 'A Mocksville,NC 27028 Subdivision Name: ! Phone#:704-634-8760 - Directions to property: f/l If f Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:#` - ��4 .,,. Road Name: 49� . 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 1 I of G.S.Chapter 130A,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 7 0 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION p `.Perms _ Nalne" ""e r r .. rte- _ Subdivision Name: -'el m1""J Directions to,,property: Section:_ Lot: IMPROVEMENT PERMIT Tax Office PIN:#-n ,f. - "`!. a - Road Name• �'/ C3:• 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 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***T111S 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—1,T--#BATHS 2 #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SUE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)'Z�Oe4F NEW SITE lf� REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE/Ob b GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH�� LINEAR FT.--goo l OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT **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 DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760. OPERATION PERMIT K YS INSTALLED BY: LLLLe�LO x fl . �2L Notes. fOoAT I AUTHORIZATION NO. 0 OPERATION PERMIT BY: DATE: `7 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO 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 WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI Davie County Health Department 0 V 9 Environmental Health Section P.O.Box 848 Mocksville,NC 27028 MAR 2 4 1998 (336)751-8760 ENYIRONh1ENTAt HEAlTi ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS UNLESSAVIE COUNTY ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 44 u r it Contact Person Mailing Address ) W v C/o J t—J c4 r� lee— Home Phone City/State/Zip NO L JtS co/(F /�_� ' Business Phone !F 5 3 5t G s 2. Name on Permit/ATC if Different than Above �i✓ `t y''�" 7 Mailing Address & 71 Ma,A' CA City/State/Zip J�-�s 3. Application For: ❑ Site Evaluation I Improvement Permit&ATC ❑ Both 4. System to Serve: lK House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms �_ # Bathrooms �— sCl Dishwasher Urbarbage 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: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ZNo If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A% THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: .3'31600 1 WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: #.S � �— 73 - US ! ILV Property Address: Road Name SLt r�1 �L� 1 City/Zip 2 761.� 1 If in Subdivision provide information,as follows: I Name: S U/M��'1G`�i2 45✓' 1 Section: Lot #: 2-- 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 E to %s A"I lkr A �eh- 4 to conduct all testing procedures as necessary to determine the site suitability. DATE 31)L-4 r�1 [ SIGNATURE ' Revised DCHD(06-96) YOU MAY USE THE $ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. L C.ow cob►It*Ww twr AnvWIt►p� go"yr�K WM d th.wwq OR b/wb/aft ICI W Sri • `• z � ` w w.�..~i��wit Ms w sr�ws46 tlrt� . O . a the Mb pbt b d.=wr Od b WOW b .«w of d em*or ssstodw VA b w.~•b w rdbws� *A sus/w"i 46%N* ' a %A 06 od b 0#rMW d'w�y IWw1 or Mwb or bwdj L IbA 90 rM b Of•wrwr M V~rd ,t,Vwb w ter wwdrAl� of rMq pwwft,a wtt-rdwM wow or AAr ON""to M doodba 46 9960AJrt rsMr b ai.Mrsirn to*A Wd of qr perdu/ d ft w b PWA41W r kft"b(0)IWAw(40 46wa C �f Registered Land Surveyor N0. 2623 / Parcel 29.08 John M. Clement D.B. 194 — 626 -�� NIP new line 8855 55 E S . 47.26' 104.23' NIP NIP 93.63 f/P so RIC (bent) (bent)I V.,6= c°rner. 86,7,5. U) In M tND N N Parcel 29.09 N Avery C. Clement Estate vn D.B. 43 — 332 M ,x<: .. o 0o_ v, l��4646 o N 34532 Sq . Ft. W 3,000 S , YU 30002 Sq. Ft. to RW 30000 Sq.Ft. to R N ,Z O 0 0 0 0 EIP NIP NIP (A W O � O Z 1643 r.r. spike found 100.00' point in aIJ' in cl � 155.93' point in cls' N 82047'25"W 363.70' n Rd . - - Notes: 1. Avg. lot size to R/W = 30015 Sq. Ft. 2. Property is not in a Flood Hazard Area. 3. All lots are to be served by individual sewage facilities. 4. All lots are to be served by county water. 5. Property is Zoned R/A 6. Minimum setbacks Front = 40' ' APPLICATION FOR SITE EVALUATIONAMPROVEMENT P r� Davie County Health Department Environmental Health Section D P.O. Box 848 JUL 1 6 1997 Mocksville,NC 27028 .10 (704) 634-8760 ! ****IA?� )RTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to )e Billed N Contact Persons Mailing Address � � r/J Home Phone ��" :5 6 '1-!5' City/State/Zip A G c u()I e •��/ �' i Business Phone (J 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: r-Site Evaluation [ ]Improvement Permit&ATC [ ]Both 4. System to Serve: [V ouse [ 1 Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People #Bedrooms Q— #Bathrooms [dishwasher[ ] Garbage Disposal [ ]Was>iing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals #Water Coolers 1` If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. ,Type of water supply: [vcounty/City [ ]Well [ ]Community 1 t. 8. Do you •riticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No If yes,w; at type? EITHER A PLAT OR SITE PLAN -?ROPERTY INFORMATION REQUIRED:***IMPORTANT***A: 'VOF THE PROPERTY MUST BE SUBMITTED WITHAPPLICATION. Property Dimensions: D r WRITE DIRECTIONS(fromI��Iocksville)TO PROPERTY: Tax Office PIN: # L6 -! c��,rj_'/A t7,,� �S� � G ' Property Address: Road Name��jr✓ � � r yyyy�� City/Zip �/1L �_Ile- If DL �� I lG 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. 1, also, understand that I am responsible for all charges incurred from this,application. I, hereby, give consent t(, th, luthorized Representative of the avie County Health Department to enter upon above described property, located in Davie Co.: ty —A owned by � �/I ti conduct a testindures as n essary to ,tetmine the site suitability. DATE' JZ^- SIGNATURE C Revised DCHt: (06-96) THIS Ak:iA AlAJ 13E. USE) FOR DRAIVINC7 YOUR SITE PLAN: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_LOTS Soil/Site Evaluation APPLICANT'S NAME /J DATE EVALUATED PROPOSED FACILITY + PROPERTY SIZE SUBDIVISION ROAD NAME Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH + Texture groupG 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 AZIS 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 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(O1-90) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ ■■■■■■■■■e■t■■■t■■■t■■■■t■■■■■t■■■■■e■■■t■■■■■■tt■■t■■e■tt■■■■■■t■ ■■■■■■■■■■■■■■■t■■■■■■■■t■■■■■t■■■tee■■■■■■■■t■■■■■t■■■■■tt■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■tt■■tt■t■t■■■■■tet■■tt■■t■t■ ■■■■■■■■■■■■t■■■t■■t■■■■■■■■■■■■ MEMNONiiiiiiMENNENiiiiiiMEMNONMEMEMEMMEMEii s■■a■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t■tt■t■t■e■■t■■■ttt■■■ttttt■■ noun ■■■■■■t■■■■■■■■■t■■t■t■■■t■■tet■ ■■■■■te■■■■e■■■■■■■tttt■■■■■t■■■ ■■■■■■t■■te■tt■■t■■t■tee■■e■■tt■■■■■■■■■■■■■■■e■■■■■■tttt■■■■■tt■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■t■■■■■■■■■■■■■■■■t■t■■t■■■tet■ ■■■■■■■■t■e■■■■■■■■■■■■■■■t■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■