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137 Hidden Valley Lane Lot 5AUTHORIZATION NO: ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee'~ / P.O. Box 848 Name: Mocksville, NC 27028 Subdivision Name: i Phone # 336-751-8760 Directions to property: y% ,% �` •`�, ' � '�, �� j �- AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Section: Lot: Tax Office PIN:# Road Name: Jul r�"k: **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) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION d IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED DAVIE OUNTY HEALTH DEPARTMENT TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permitee's ;.,,Name T /-S'L Subdivision Name: / e E' Directions to property: Section: f Lot: IMPROVEMENT PERMIT Tax Office PIN:# �. o L r Road Name: 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 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 T # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or 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 -e-' ROCK DEPTH/ LINEAR FT.� 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 THE DAY OF INSTALLATION. TELEPHONE # IS (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 NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) ,'�} '� '�. till l� i' �A. ..1 `• ,. � . , '. � - .. _. .. DAVIE' OUNTY HEALTH DEPARTMENT -Y~ IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Perm4tee's , / ,.Name: w (� % sC� Subdivision Name: e C't Directions to property: Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name: **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 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or 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 C ROCK DEPTH 9 / LINEAR FT. /i 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 THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT AUTHORIZATION NO. OPERATION PERMIT BY: SYSTEM INSTALLED 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) r� / -Ire DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT / NAME h�e�c. 7�1-�-�- PHONE NUMBER " / 1�-6d,�4 ADDRESS 5 q a- L -i -,SUBDIVISION NAME AaL-� DIR CTIONS TO SITE b d 1N• 1��,1[�„ Lam, DATE SYSTEM INST SUBDIVISION LOT # NAME SYSTEM INSTALLED UNDER 4/"5Q—�- SPECIFY PROBLEMS OCCURRING D 4i&7x'/1—Le ale tA 4 � DATE REQUESTED INFORMATION TAKEN BY lac Aee--11�'Filt -D ��ood-R) `7� 01 ccs IMPROVEMENT PERMIT DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT �a **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) NAME PROPERTY ADDRESS n DATE— j LOCATION SUBDIVISION NOME /4� l/r�1 G�/� L� LOT NUMBER _ SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE tin # BEDROOMS S_? # BATHS c ` # OCCUPANTS -2 GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE A) P TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 114NEW SITE LZ REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE / [i/J GAL. PUMP TANK GAL. TRENCH WIDTH j,_ " ROCK DEPTH A2 "'LINEAR FT. D(� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. D IMPROVEMENT PERMIT BY ZA11 // **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 AUTHORIZATION NO. SYSTEM INSTALLED BY 1 �� o �-4 0 O OPERATION PERMIT BY ! d� � Fo G �ti **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 138A, SECTION .1900 -SEWAGE TREATMENT AND DISPOSAL SYSTEMS -,-BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOPILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 0 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM T RECEIVED D Davie County Health Department Environmental Health Section J U L – 6 199' j 1 P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address �� 8 D�/P Home Phone 91911? ` /j% _ g��' /�%�Y1 �,� /� r G 2 7aZ b' Business Phone 2. Name on Perm if, different than Above 3. Application for: General Evaluation O Septic Tank Installation,Permit 4. System to Serve: Houses.. Ak1,64,F tO U Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry her / ❑ Unknown 5. if house, mobile home: Subdivision �� / ii ��` Section Lot # -5 s 44VJVAJ $, ��3 ��.t�C Yje,�C%S ❑ Basement/PlumbingNo. of People ❑ Basement/No Plumbing i. No. of Bedrooms TO -3 b�.�1? ! ❑ Washing Machine No. of Bathrooms Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories _ j' No. of Showers 7. Type of water supply: ❑ Public 8. Property Dimensions No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures ❑ Private Sewage Disposal Contractor 0 Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility his sytem is intended to serve? ❑ Yes ❑ No If yes, what type? ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: �-- This is to certify that the information provided is correct to the incurred rom t s application. Q(% DATE of my knowledge, and I upoerstand I am responsible for all charges IGNATURE CONSENT FQB SITE EVALUATION TQ 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 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. DCHD (1/93) DATE SIGNATURE " DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME I ZLIAI� ADDRESS PROPOSED FACIILTY/ DATE EVALUATED PROPERTY SIZE 1.�C AGS LOCATION OF SITE Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit // Cut FACTORS 1 2 3 4 Landscape position Sloe % 112- 57 - HORIZON I DEPTH Texture grouP Consistence Structure Mineralogy HORIZON II DEPTH Texture group` Consistence 77 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 t. SITE CLASSIFICATION: ��` EVALUATED 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 ,lay loam• SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR-Ve-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 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 avie County Hea th Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) ***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.*** NAME �i��P'S �?/iy�� DATE AUTHORIIRTIONJNUMBER NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM **WICE*H THIS AUTHORIZATION FDR TEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE DCHD 10/95