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171 Serenity Hills Trail Lot 8R -q..—:.e:x�`.r - � ,. a, s - •- �, .'yCw. v i.. - ,Fy a'� ..' rt. AU`T'HORIZATION NO: 9 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee 's� ¢ P.O. Box 84$ �! , �`'f`,� ' Name: +t� B Mocksville, NC 27028 Subdivision Name: ����?� r Phone # 336-751-8760 Directions to property: ;1;1!� !!1 J� C Section: Lot: 4a AUTHORIZATION FOR WASTEWATER, �" SYSTEM CONSTRUCTION ' Tax Office PIN:# .5 rr r- - +•*: Road Name: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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) �/„/ ,` // ',�/`�AlLf ` ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ll y' �C�' SCJ • ,7y 1�;1�..?/..g% / %0 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPE DATE ISSUED a , DA . D PAR W .. / ao 411- VIE COUIyTY HEALTH E TME IMPROVEMENT A OPERATIONPERMITS. PROPERTY INFORMATION PemutCee's ; Name s Subdivision Name: / I . • ;. �� -� ,...�_.• . jjeet .�., ._ _ .. ', .:--. ..:.�.. �� • 'Directions to -property a '� .T :�' Section A " 'Lot.. � , • ,. ILt4PROVEII�NT .. ,', . ' - • PERMPP Tax Office PIN:#- - Road Name: Zip: ' **NOTE*•*•This Improvement Permii DOES, NOT authorize the construction or installationof a septic tank -system orany wastewater system An AUTHORMkIlON FOR WASTEWATER SYSTEM CONSTRUCTION.. must be obtained fivm this Departmentprior to the constiuctioii/uistallafion of a system or'the issuance of a building permit, (In compliance with• Article l l of G.S: Chapter 1+3oA, Wastewater, Systems, Section .1900 Sewage Treatment and Disposal Systems) a . �f j s ***NOTICE*** TIUS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INII�NDED USE CHANGE. YOUR WASTEWATER t :. SYSTEM CONTRACTOR MUST SEE TIUS PERMIT BEFORE s .: j,. ENVIRONMENTAL ftEAL•;TH S IST • DATE ISSUED 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'WATEIt SUPPLY Lr/�ll DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE �'. 1, . SYSTEMSPECIFICATIONS: TANK SI � GAL. PUMP TANK � GAL. TRENCH WIDTH �(o ROCK DEPTH '�Af 1, 'MAR FT. OTHER. AMA, 1/k',(/O .REQUIRED SITE MODIFICATIONS/CONDITIONS: OPERATION'PERMTf G n SYSTEM INSTALLED BY%l e��. e� ,� IV A�, !A4]ION FOR SIIE EVALUA]ION/IMPROVEMENT PERMIT t Davie County Health Department / ��✓ �,2� EnV#Vnmenfa/Meaft 5L+cf/on P.O. Box 848/210 Hospital Street FEB 26 1999 ae%,� Mocksville, NC 27028 (/� (336) 751-8760 �,,,,Q�Nh�EpiTAI HEAIJN ***IHP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALS REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ' 1 I Contact Person l 1 I or I MmV Mailing Address 1 3 3 I � � <sY) 51f Boma Phan, 19 OG - 5 34 q 1 City/State/ZIP A Cy QZn - n1C 2%,o a(, Business Phone -] 7 2. Name on Permit/ATC If Different than Above Mailing Address City/State/Zip 3. Application For: N Site Evaluation 0 Improvement Permit/ATC OBoth 4. System to Service: 2/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. IfResidence: #People l # Bedrooms -3 # Bathrooms -z tYDishrasher 0 Garbage Disposal gashing Machine U Basement/Plumbing gement/No Pluming 6. If Business/Industry/other: Specify type # Cammodes # Showers # People # Sinks # Urinals # Nater Coolers IP FOODSERVICE: 11 Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 0 County/City is ell 0 Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve! ❑ Yes "o If yes, what type' ***IMP0RTANT*** CLIENTS AfUSTCODIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PIAT or SITE PLAN MUST BE SUBAHI TED by the client with THIS APPLICATION. Property Dimensions: 7 S WRITE DIRECTIONS (from Mocksville) to PROPERTY: 01 Tax Office PIN: # 5 (-03 - y 9 - S 7 7 `% .DMP) 8 D \ Cy-; 4- ko `1 adk; n UQ I I e.. -y ✓er �(\d ; 11.5 r)5n4 n Property Address: Road Name 0 h City/Zip "Mo (o If in a Subdivision provide information, as follows: Name: 01 (5 DAV; �Av � M, }-�ctt�eS Con-1rac��n.�c• ��- Section: Block: Lot: Le44 on San � p + / L e,1-4 1a1 6 iVer he /I gads 1 L,,ue r —7 Date Property Flagged: 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 responsiblefor all charges lncurrrd from this opplication. 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 byDa\11� Ci ,1 e S to conduct all testing procedures as necessary to determine the site suitability. z9 DATE - 02 L - 9 9 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Ibclude all q/the property lines and dimensions, structures, setbacks, and septic locations). / � No4 e _ Land purcho s- - Revised DCHD (07/98) e1vs,q 5 ,n mafc. , Existing and proposed Account No.� Invoice No. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE 019 PIS, p W— M Davie County Health Department — Environmental Health Section P. O. Box 848 DEC 4 19" Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL Ltt THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Z n.It 113 fi \ . t"tG +, e s C� .-1L. Contact Person ! -v no V6.% -P_ S Mailing Address 3 d 1 �A C. t S I Home Phone 1"I to 5'JI $ —L 3 City/State/Zip A Sl ue- r+GG N - L. Z do 6 Business Phone 4 �° er 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: ❑ Dishwasher City/State/Zip 9— Site Evaluation ❑ Improvement Permit & ATC ❑ Both 9 'House ❑ Mobile Home K; ❑ Business ❑ Industry ❑ Other # People # Bedrooms # Bathrooms ❑ Garbage 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 tMell 8. Do ;you anticipate additions or expansions of the facility this system is intended to serve? Tf vec_ what tvne? ❑ Community ❑ Yes ❑ No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE ISUBMITTED WITH TRIS APPLICATION. Property Dimensions: Z. G AD aliL� 1 WRITE DIRECTIONS (from Mocksville) TO PROPERTY. Tax:Office PIN: # SFS G 3 Al, � j,r x Property Address: Road Name` / ' /O r,,,/�/�' /� �� ) City/Zip d V � � G' � . � ! M 11110 (T 7�� .�hd-P If in Subdivision provide information, as follows: 1 �� i e n 1 Name: ) I �° iO e L GL 164 ks- Lot #: 1 r 1 ar l 1 Section: 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 I'D a .r % 0 AN e_ s C•o +�, �^� r '� I •, � C_ , to conduct all testing procedures as necessary to determine/the site suitability. DATE , L �� l SIGNATURE All, Revised DCHD (06-96) I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION__ LOT- Soil/Site Evaluation APPLICANT'S NAME �J/.ghiA� DATE EVALUATED PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well -- - Community PROPERTY SIZE ROAD NAME Public - Evaluation By: Auger Boring Pit `� Cut FACTORS 1 2 3 4 5 6 7 Landscape position le A /10 Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH '" d Texture group Consistence 41111 Structure xr Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: '12� LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND DCHD (01-90) Landscape Position EVALUATION BY: OTHER(S) PRESENT: 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 on ■ ■ME■EME■ ■O■■EM■■ ■c■■E■E■ ■EMEMEM■ ■O■■■M■■ ■■OMM■M■ ■M■■MME■ ■EMMEME■ ■■ME■■M■ ■■■MEMM■ ■E■■■■■■■■Mee■■■/el/eeeee■/ecce■e■Mee■■e■■■e■ ■■■■■Mee■■■■■/■Mee%e■■■■ecce■■/eMee■■/■■■■■■ ■■■■■■■■■Mee■■■■■II/eee■Mee■■■■�■■■e■eee■e■■■ ■■Mee■■■■■Mee■■■�■■■e■■■Mee■■■■/eee■■■■■■■■■ ■■/■■/■■■■/■Mee■►I■■/eee■■/■■■eee■■■■■■/ecce■ ■■EE/cc■■■/■■■e�■■/■■Mee■■■■■■■■■■■c■■■■■■■■ ■Mees■■■eee■/■eeeee■■■■■■ecce■■■eee■eeeeee■ Mee■■■■■eee■e�■/Mee■eMee■M■/■ Mee■eeeee■■e■ ■■/Mee/■■■/■It■■■eee■■■■■■■■eee■■/E■/■■■■■■■■ ■■■■e��e■■■elf■e■Me■M■■MeeMee■/■■■■M■/e■■■■■■ Mee//■■■eee■tl■■■/■eMee/eMee■■■■Mee■M■■■■■■■■ ■MeeMee■MMer■Me■e■■Mee■ecce■eee■■■e■eeee■ee■ ■■■■■■■■■■/■Mee■■■/■■■■■■■■■■�■■/■■■■■■■■■■ MeeMee■■eeeeeeeee■eee/■■eee■ Mee■eee■e■■e■ ■/■//■■■/�■■/■■/■■■■/■/■/Mee■■Mee■■■■■■■■/■■ ■■/■■■M�%Mee■■■■MeeMee■e��e■■■■■■■■ec■■e■■e■ ■■e■■e�■ecce■e■/eeeeee■eec■ee■ee■ee■M■■e■■e■ ■/■■■I■■■■■■■■■eMee■■■■■Mee■M■/■■■eMee■Mee■■ MEMEME MENNEN MENEM ■////■■■e■eeM■■■■ecce/■■/eMee■■/■■■■■■`M■■■■ ■I■■■■Mee■■■■cell■■■■■■■■■■■■■■■■■■■■■eeeeee■ II/O■■■OEM■O■■■■■�■/■■■■■■■■■■■■■■■■■■■■■■■■■ e■■Mee■■■■■■/■eie11■■ecce■eMee■eee■■■■Mee■■■I ■■■■■■■■■/■■■/■■■■■/■■■Mee■■■/■■■■■■■/■■■■■■I ■■■/■//Mee■e■■e■/eeeeee■M■■Me�■■M■/■■eeeeee ■■■■■■■/eee■■■■■■■■■■//Mee■■■ ■EME■■OMMOM■■ ■/■■■■■eee■■■Mee■eeeee■Mee■■■Mee■■■■■■eeeee■ ■■■■ecce■■e■Mee■e■MeeMee■e■■ee■ecc■■e■/■Mee■ ■■■■■■■■■/■■/■■■■■■■Mee■■■■■■■/■■■■■■/■■■■■■ ■M■■e■■■■■■eMee■■eMee■■/■■/■■■■■■■/■c■■eee■■ ■■ecce■Mee■eeee■Meee■■e■■■■■■■eeeee■■■eeMee■ ■eeeeeeee■■■■ee■■e■ee■■eeeeee�■■■■eM■ee■■e■ ■■■■/■■/■■e■■■■■c■ec■■c■/■■�a ■eee■■/■■■■■■ ■■ecce■■e■ce■c■■■■/■■cc■■///ecce■eMee■c■■■■■i ■/■//■■EM/■ecce■/ec/Ec/EecE■■cc//e■E■/Eec/El� ■Mee■■/■■e■■■■■Mee/■■e■c■■ec/ee■e■■■■■e■Mei■ 0 ■EM■■ ■ ■ ■■■■■ ■MEM■ MEMO MEMO ■EM■ MEN MEN ONE