206 S Angell Rd Lot 3 AUTHORIZATION NO: Q 6 2 6 DAVIE COUNTY HEALTH DEPARTMENT J�
Environmental Health Section PROPERTY INFORMATION
PerrnAese's / P.O.Boz 848
Name. .,- / �.�- /
/76164'el / ,,1�' Mocksville,,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property: ° Section: Lot:;
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#� /44
SYSTEM CONSTRUCTION 11�
Road Name, N e d-Zip: DMr
*NOTE**This Authorization for Wastewater System Construction MUST,BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen-nits.This Fonn/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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�" k r IS VALID FOR A PERIOD OF FIVE YEARS. .
ENVIRONMENTAL HEALTHPECS IALIST
:DATE ISSUED' '• :- ".
_;r I-Ir..'•�4 y-..Mir+ily .r%v R� i'a's� .,,. -.iy i'..y�tR �. vt"',.xn Fir'+s` s,.rw;.; -y::y.L y:�,a..a<-} a'r'Y..�� tJ.,.� •v >'•;�
DAVIE COUNTY HEALTH DEPARTMENT
-" IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pe
Name:. 'Illy 1111*<< "?�i��a �.r': -f-,/� ° Subdivision Name:
Directions to property: ,r rfi i� Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
Road Name t G C •Zip: r c'%' r3 -.
**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
; / .1 PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE_.dW'H #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZER TYPE WATER SUPPLY r 0 DESIGN WASTEWATER FLOW(GPD)a NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE ZO GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
:r
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 THE DAY OF INSTALLATION.TELEPHONE#IS(704)6348760.
OPERATION PERMIT Q
L SYSTEM INSTALLED BY:
Ott
fl �d
w -
AUTHORIZATION NO. / OPERATION PERMIT BY: DATE:���/-I/
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 05N6(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMITTV-
` Davie County Health Department 5
Environmental Health Section
P.O.Box 848
Mocksville,NC 27028 JAN -- 8 19997
(704)634-8760
LAS" IT1111171-Ir
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED LESS fC`r't.nj
ALL THE REQUIRED INFORMATION IS PROVI
1. Name to be Billed Contact Person� !
Mailing Address Home Phone &D
City/State/Zip �' ' ,Ir, GG k-- J' / � Business Phone - SD
2. Name on Permit/ATC if Different than Above ru .7u/�i J
to A -to Cit /State/Zi �l7
Mailing Address y p
3. Application For: a Site Evaluation id Improvement Permit&ATC ❑ Both
4. System to Serve: ❑ House 21 Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms ! # Bathrooms
❑ Dishwasher ❑ Garbage Disposal 0 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) / per
7. Type of water supply: ❑ County/City ElWell r' Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Jk No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: Z 99 I WRITE DIRECTIONS(from
n Mocksville)TO PROPERTY:
Tax Office PIN: #
S
Property Address: Road Name
/
City/Zip �L'L V-/
If in Subdivision provide information,as follows:
Name: YZ ,t ,17C1.2 L
1
Section: Lot #:
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 pro ures
as necessary to determine the site suitability.
DATE �� _ SIGNATURE
Revised DCHD(06-96)
C.RAY CATES certify that on March 03 ,'.1994 , I surveyed the property shown on .a:.; pial: t
that the property lines and location of all structures are accurately shown,hereon; .that no structure Located on this property'
encroaches on any adjacent street or property, and that no structure'on adjacent 'property;*.encroaches on the prernis
3 surveyed."
ll�,t �
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e
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Q• SOUTH ' ANG�LL ROAD
N 43°- 47�- 41 E N 42°- 57'E 'rt►flu
1 .
68.51 46.38
'lion found `—
iron — point
found �20 ospholt M
1,300 —' ' to
Main Church Rood R/W as ctmmetl
(S.R. .1405) by N.C. OOT
.r• a LOT .4 tr
LOT 2 6,
Z
At1 i r
1 892 'AC '�
(by d.m.d.) {
CD
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'<y' tj Iron Iron
found _ 200 found
branch S 4 20-04 -5S' W
i` JAMES i'THOMAS . PILCHER, JR
D. B. 130-134 t.
PROPERTY OF - _
GWENDOYN SHERRi LLfi� '
T .
Ali. 3 WILLARD` SUBDIVISION
;LOT NO. MAP OF BLOCK NO.
PLM MOCKSVILLE IDW SIHIP,
AT BOOK 6 PAGE 25 DAVIE COUNTY1N. C.
} SCALE: 1 INCH 100 IrEET
JOB NO 3240
Lr ,r s
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiUSite Evaluation /
NAME �I'.�/G� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY '� LOCATION OF SITE
Water Supply: On-Site Well Community Public L/
Evaluation By: Auger Boring Pit r/ Cut
FACTORS 1 2 3 4
Landscape position L L G Slope % .�
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 4110b1 Iry
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 ,S77
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY: I`1`t*'f1
LONG-TERM ACCEPTANCE RATE: _e � 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(01-901
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