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2042 NC Hwy 64 E Lots 1 & 2Xo AUTHORIZATI )N NO:132 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permitted's P.O. Box 848 — M Name: Tfttc g. K.lC�IS• Mocksville, NC 27028 Subdivision Name: lftwe 4.�R F Phone #: 704-634-8760 Directions to property: OtJY t7i. -� Section: Lot: 1-� z AUTHORIZATION FOR %` T r -v(( n1fi��.P,. 0D WASTEWATER Tax Office PIN:#� - ' a 191 SYSTEM CONSTRUCTION Road Name: H Wtt'l;,nt%L zip: G %v= **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 1 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. IR6 MAL HEAL SPE , ST DATE ISS ED t ' • APPLICATION FOR SITE EVALUATION/IMPROVEMENT 1�IT Davie County Health Department { Environmental Health Section JJf P. O. Box 848'``" a3 L098 Mocksville, NC 27028 a , (f@9PqWXXX (336)751-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed `��i 1 C, (,1 r Le Contact Person 41, z, Mailing Address 'P. 0 • B a X 17 i Home Phone .: 36 c Z 702 R%;77 City/State/Zip roDr',C..5V I Ile, /U Ci -7o-4fBusiness Phone ':7gZ 2. Name on Permit/ATC if Different than Above Mailing Address _ 3. Application For: 4. System to Serve: 5. If Residence: NX Dishwasher 6. If Business/Other: # Commodes _ If Foodservice: ❑ Site Evaluation 0. House ❑ Mobile Home # People -4:1— City/State/Zip Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms s- Exr- agp ❑ Other # Bathrooms ■ i• M SL Garbage Disposal If- Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 7. Type of water supply: Specify type # Showers _ # Seats S4 County/City # People # Sinks # Urinals Estimated Water Usage (gallons per day) ❑ Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes ❑ No EITHER PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A IjLY" THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Z G D /,� �v Dy / WRITE DIRECTIONS (from 5-?�--T *7k, S-9 81 Mocksville) TO PROPERTY: Tax Office PIN: # - - 1 1 wit to GS �% ►►�: (ray Property Address: Road Name / t-- wV l0 1 City/Zip "06'eJy/l� 17C- Z7OZY ' 1 If in Subdivision provide information, as follows: 1 1 Name: :712, r e -e LP 1 1 Section: Lot #: l q'I 1 on c h tom- on 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 determine the site suitability. n DATE SIGNATURE /i o ��! (A.A& Revised DCHD (06-96) YOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. IR APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 fry 1 31998 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSES 1 THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed n tJl e -r Contact Person 6 anc, en- Mailing Address !�, 5.� J Home Phone a a'�9 City/State/Zip f)&JanCQ- NC �'lm(o Business POO— a `3 gn- 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [V�Site Evaluation City/State/Zip [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: [House [VMobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People _ # Bedrooms # Bathrooms I. S [W"Dishwasher [ ] Garbage Disposal NV Washing Machine [ ] Basement/Plumbing [Aasement/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 VNo If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: I �6' x 5(4q / WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #-5,7�7 - 17 e 14 lx� �� f c3Y1�- (YAoL'.Vsji I�Q_ Property Address: Road Name Ina t kQ S n r 1 AKk City/Zip u C If in Subdivision provide information, 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. 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 determine the site suitability. DATE /02- - �6 SIGNATURE /�.i,: Revised DCHD (06-96) OF/ ,oris ,o�� 1# t, DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permitt s Name: - A-avc-tSubdivision Name: lvi°meg U&r— r �� r tf, �+ Directions to property: r ` ^ . �t ( i.� F < �. Section: Lot: IMPROVEMENT t d 5 ')5y `,1 f �t €i�f. •:: PERMIT Tax Office PIN:# - Road Name: i,;tll.�t/ 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*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE '• - '� �, `' =�- % �k" PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPEMAL'IST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPED # BEDROOMS _—� # BATHS 2 # OCCUPANTS 2- GARBAGE DISPOS ester No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No i /11 t LOT SIZE 20y�� TYPE WATER SUPPLY Y DESIGN WASTEWATER FLOW (GPD) c3�'� NEW SITE f REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE rL GAL. PUMP TANK GAL. TRENCH WIDTH, / ROCK DEPTH �2 / t LINEAR FT. / C0 / OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: { O STA LL 00 G2JIO i- L L -P S' F f 00 0S "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 eB ljl 1;,ji o N SYSTEM INSTALLED BY: AUTHORIZATION NO. 1 OPERATION PERMIT BY: �,� DATE: 6 < I "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) ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 2C.Z L 20OS-1 ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE 45 c LOCATION OF SITE _C, %�✓ Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring L__ Pit Cut FACTORS 1 2 3 4 Landscape position L.21 Sloe Z HORIZON I DEPTH 'e• -y41 Texture groupe Consistence Structure Mineralogy HORIZON II DEPTH Texture group (10 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 CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: OTHER(S) PRESENT: 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- V+ ---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 Mineraloey 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 P';1 APPLICATION FOR SITE EVALUATIONAMPROVEMENT ****IMPORTANT**** Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 � .E MEIR L INS 01 P-0 • THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed o Contact Person 5a ryu— Mailing Address 5 Home Phone q I-II 0 —'a:ZILO City/State/Zip \O -Q glri0( (C' Business Phone ��S — 13qI eXt3dg�. 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [[/Site Evaluation [ ] Improvement Permit & ATC 4. System to Serve: [House ['►Mobile Home [ ] Business [ ] Industry [ ] Other [ ] Both 5. If Residence: # People-_ # Bedrooms— # Bathrooms 1.5 [t,�Dishwasher [ ] Garbage Disposal VWashing Machine [ ] Basement/Plumbing [vBasement/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: [VCounty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes VITO If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: 130 ` X 5C�`1 / WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #576-7 - r% - B W lA • (o A E-Vrro►'Y� Property Address: Road Name W C "W� (Vq a 'Lk S U \ I, e `A h-\ t City/Zip C, n A-NNe If in Subdivision provide informationn� 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. 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 determine the site suitability. DATE L SIGNATURE�l�i, Revised DCHD (06-96) a119 /2o' i�. NAME S61,dZl— ADDRESS PROPOSED FACIILTY DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation DATE EVALUATED !� PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well _ Community Public I Evaluation By: Auger Boring I Pit Cut FACTORS 1 2 3 4 Landscape position Slope % ` HORIZON I DEPTH 41 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 CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: y2�__ EVALUATED BY: At LONG-TERM ACCEPTANCE RATE: L— 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- V -::-y friable FR -Friable FI -Firm VFI-Very firth 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 Mineraloiry 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