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150 Winchester Road Lot 9Permittee's> D VIk COUNTY HEALTH DEPARTMENT Name:tE��a REQUIRED SITE MODIFICATIONS/CONDITIONS: a Jlr4 ,EPvironmental Health Section PROPERTY INFORMATION �?��U P.O. Box 848 f Directions to property: Mocksville, NC 27028 Subdivision Name: ( MjPhone 0 �1 l wt A �-04 61 C-�P #: 336-751-8760 Section: Lot: -� AUTHORIZATION FOR WASTEWATER A/ Tax_ Office PIN:# $�j� P/� T�y� 0 ^iT ts7 SYSTEM CONSTRUCTION A y +} A/ j 1 4/6 VV1"C`, r-) 1/Cif f�l 1 ry hA AUTHORIZATION NO: a Road Name: G Zip: rG(� **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) s' ,� ✓' j , ,�J % *-**NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ' " � �°`f `• r % � l-- IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE �2 # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZETYPE WATER SUPPLY ` DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE I� G _ AL.( PUMP TANK / GAL. TRENCH WIDTH3�1 ROCK DEPTH LINEAR FT. J OTHER (J t rLrl 7T=� �` Lt"Id I L, V, Su'! �-C.-I ` REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT b6x IV e Lk) 5 f 5j .c-`r'A 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT LL SYSTEM INSTALLED BY: �p,� C"P u rJ V -"'P7 S Oft7 clif ew t�� o� u f�� a AUTHORIZATION NO. PERATION PERMIT BY: DATE: '!J `Ll ` **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. DOM 02102 (Revised) Pj Ct %q N} L�`7 �! l i (1 • �I t`� r"11�' jj ✓ Pex�nictee's ( t DAVIE COUNTY HEALTH DEPARTMENT Name-�t t O+i "''`' / v ����►�'cr,F�nvironmental Health Section PROPERTY INFORMATION P.O. Box 848 ; f. Directipns to. property: Mocksville, NC 27028 Subdivision Name: i l.t 1� (' k' 4 I ►' 1� y}t �� �' ' Phone #: 336-751-8760 Section: 1 Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# r (d 'r "/ L SYSTEM CONSTRUCTION AUTHORIZATION NO: 0 0 "' A Road Name: ' '` �v:, Zip: c— **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) { �� J� iJ r �� y '� ***(�jY�/10TICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS # BATHS # OCCUPANTS -5 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No 1 UG q A.. / LOT SIZE �' TYPE WATER SUPPLY ESIGN WASTEWATER FLOW (GPD) a O NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE -'i G1 G GAL. PUMP TANK 1 rGAL. TRENCH WIDTH ROCK DEPTH 2�0 LINEAR FT. d OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED BY: Tl v!g y(!t 1 17 c i( b, A. AUTHORIZATION NO. ?C OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 02/02 (Revised) {{ll f Z�(-( / F J+Y' I4,n DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Alt � �6 1 APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) per - NAME -Te nn; R-9 I U r M PHONE NUMBER F446 macfid Zfe7-6coti'R On( ADDRESS Iso W 1^ ahe441Al FJ SUBDIVISION NAME 1un�dl A J U iamet- (IL Z? cry 6 LOT # 9 Ott new Pb -`nt DIRECTIONS TO SITE I SFS - T ?-- gur. Club RJ - R4- Ar W DATE SYSTEM INSTALLED of V NAME SYSTEM INSTALLED UNDER lz.k AndjAtr, Cuj4- TYPE FACILITY 'k NUMBER BEDROOMS -3 NUMBER PEOPLE SERVED -3 TYPE WATER SUPPLY 004"T SPECIFY PROBLEM OCCURRINGutntnM /►!�' Pi1•.'I-•>� Flwd Indr- UJk- Fen, RA It ad%,,!n La s DATE REQUESTED 4-1-01 INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1193 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT **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 1t of 6.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME PROPERTY ADDRESS AA Jf 7'/Cry l7 `/`C� �'� /-�d" • r ' ATE LOCATION SUBDIVISION NAME /4`�;� k `7flr �✓ �" `� / LOT NUMBER SEC./BLOCK NUMBER % RESIDENTAL SPECIFICATION: BUILDING TYPE • f #BEDROOMS # BATHS .�/1 # OCCUPANTS GARBAGE DISPOSAL: Ye IIo ._..- COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE :%f°/ TYPE WATER SUPPLY tT_ DESIGN WASTEWATER FLOW (GPD) s'`' rJ NEW SITE P-- REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIE / 2) GAL. PUMP TANK OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: GAL. TRENCH WIDTH _,� ROCK DEPTH f� LINEAR FT. ***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. IMPROVEMENT PERMIT BY fXX **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.— AUTHORIZATION Y. 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 136A, 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. ncnn in/q5 O • DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT IMPROVEMENT PERMIT to **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. AN AUTHORIIATION 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 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) PROPERTY ADDRESS //24C!/1 7ci'� �/• 4�DATE (eftfiC SUBDIVISION NAME l�,y Y/�iC" �'-��! LOT NUMBER _9 SEC. /BLOCK NUMBER / RESIDENTAL SPECIFICATION: BUILDING TYPE i. i # BEDROOMS _:? # BATHS �=—Q # OCCUPANTS GARBAGE DISPOSAL: Ye o COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE / TYPE WATER SUPPLY < DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH --T/, ROCK DEPTH /0 LINEAR FT. �Do 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. IMPROVEMENT PERMIT BY !� **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M. OR 141:3O1P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY 440 AUTHORIZATION N0.OPERATION PERMIT BY �/� DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPL.IANCE WITH ARTICLE 11 OF G.S. CHAPTER 13OA, 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 10/95 Davie County Health Department t` ENVIRONMENTAL HEALTH SECTION ,,. P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 610 (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.*** AUTHORIZATION NF3ER NAME U///te l/.o�lo`�- DATE 10 0 2 7 NAME ON IMPROVEMENTT, PEERMIT (If different than above) SITE LOCATION COMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM `i/iVC RRA APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM O LS 15 I�uCa Davie County Health Department U.y_� Environmental Health Section JAN 2 9 1996 p0� P. O. Box 665 n Q, 9.9tp Mocksville, NC 27028 1. Application/Permit Requested By ��Ge � AA)D?-Sold ,' Mailing Address (.�l ut" t1/` A✓Ex) 2-/V Home Phone d - 1 ,QJD tCe S ✓i LL -,r- C .270 :2- R Business Phone a .,a 2. Name on Permit if Different than Above R 3: Application for: ❑General Evaluation ❑ Septic Tank Installation Permit i ouse ❑ Mobile Home ❑ Place of Public Assembly 4. System to Serve: y ❑ Business ❑ Industry �� �❑ Other El Unknown 5. If house, mobile home: Subdivision e,tel+' aSlvn-S- 7 Section �_ Lot # .,. :I ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms No. of Bathrooms Dwelling Dimensions 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: ePublic ❑ Private 8. Property Dimensions Sewage Disposal Contractor 9.. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal j, ❑ Community i- ❑ Yes ❑ No i' t "NOTE: Improvements Permits shall be valid from date issued. Improvementst Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. FROPLRTY 1 Directions to Property: �rcg -14d This is to certify that the information provided is correct incurred from this application. 7— goo DATE Tax Office PIN # Road Name to.uC*e—=ST7CsC x?p Box # (if available) City of my knowledge, and I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I 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 deter 'ne Said site's suitability for a ground absorption sewage treatment and disposal system. / DATE SIGNATURE DCHD (1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation / NAME �/�//_/ �/ lS cly'/ DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY Water Supply: On -Site Well Evaluation By: Auger Boring Pit Cut LOCATION OF SITE Community Public FACTORS 1 2 3 4 Landscape position L Sloe Z HORIZON I DEPTH ! `� Texture group Consistence Structure Mineralogy HORIZON II DEPTH OE' Texture groupC G Consistence i Structure C � 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: EVALUATED BY: &j! 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- 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 5C --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