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1500 Godbey Road Tract 6Z ✓SCO A TION NO: 0 6 8 7 DAVIE COUNTY HEALTH DEPARTMENT P 6,001 1T' Environmental Health Section . PROPERTY NFS� ATIO Pe s..� � =R� aG�l`! P.O. Box 848 Name: 1F/gll �� Mocksville, NC_27028 Subdivision Name: Phone #: 704-634-8760 " riz A cvj Directions to property: Section: U11.9 AUTHORIZATION FOR WASTEWATER Tax Office PIN:#'?{rlily _ SYSTEM CONSTRUCTION Road Name:Zi ►� �a i P� �— **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) �r -77 f �y" / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION % IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTI- SPECIALIST DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT �? 1.-!.c 1-4 (r -tFIMPRO'VEMENT AND OPERATION PERMITS PROPERTY SNC l� ATIO�, as b`f ? 4 Name: Vii" -Directions ;to property: Subdivision Name: Section: IMPROVEMENT rs � PERMIT Tax Office PIN:#`� Road Name: �.,�. t ,, rr ; Zip: e` **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) ,..PIV11l C. '• 11MIMMM11 nbuninul lV 1MVVl:A17V1V U WILL t f. r' ✓ ; ��: I <"� �'f`' 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 _,:�2 # OCCUPANTS __!�/ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE IdWe TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ,�fO_ GAL. PUMP TANK Od GAL. TRENCH WIDTH _?G + ROCK DEPTH ,/:) LINEAR Fr. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT Aj/, 'S".1 0/ "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 ST LED BY: ��, .ld�!�r ?1•n� /5-° /5-V AUTHORIZATION NO. V Y/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) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE VT R 0 /7 1J - Davie County Health Department Environmental Health Section P. O. Box 848 DEC 3 1 1,996 Mocksville, NC 27028 (704)634-8760 Application For: 1. Name to be Billed Mailing Address City/State/Zip ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Contact Person Ir - Home Phone fou-qqa- Business Phone 2. Name on Permit/ATC if Different than Above -1ra if 0K Mailing Address / q5"t 1 ix c/t City/State/Zip 3. Application For: Site Evaluation Improvement Permit & ATC ❑ Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People __y__ # Bedrooms ..# r� Bathrooms nS Dishwasher ❑ 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 X Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE k- SUBMITTED WITH THIS APPLICATION. llJ t(DIRECTIONS Property Dimensions: � + C� �7 1 WRITE from Mocksville) TO PROPERTY: Tax Office PIN: # �� b - �� - (p 1 Property Address: Road Name 1 1 q City/ZipAl If in Subdivision provide information, 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 v 1��- ��'v ' to conduct all testing procedures as necessary to determine/the site suitability. DATE Q�t SIGNATURE Revised DCHD (06-96) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address "To 9 Z 2. Name on Permit if Different toan Above 3. Applica' on I )r: 4. System to Serve: ❑ House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision No..of People _ No. of Bedrooms No. of Bathrooms Dwelling Dimensions Home Phone old— 7-Y-7- 1155 Business Phone General Evaluation ❑ Septic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly ❑ Other ❑ Unknown 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: ❑ Public ❑ 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? Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal ❑ Yes ❑ No ❑ Community 'NOTE: fm~ rravementa-Rermits-shall-be-v8lid4er-a-pe6ed-ef-6-years-from-date-isotmd. Improvements Permits are subject to relocation, if site plans or the intended use change. Effective October 1, 1989. 1 1 Directions /j to Property: , _ PROPERTY INFORi•1:ATION REQUIRED: Tax Office PIN if Road Name Box # (if availabl City `�}" ,( &),pJ. eV1 YlC> This is to certify that the information provided is correct to the best of my knowledge, and I understan I am r sponsible for all charges in urred from this application. _ 6 99� ATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE UN ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1711. 1 OWN the property. 2'12" 1 QQ 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 repronative of the a ie ou 1t ealth Departn lit to er p n above described property located in Dave) County and owned �L to conduct all testing ; �iocedures as necessar dete ine saig site's uitabilit fdr a ground absorption sewage treatment Tio disposal system. DATE DCHD (1193) �IU114A 1 uhr_ Yd DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY DATE EVALUATED (qf�� K PROPERTY SIZE �Di4 C LOCATION OF SITE Water Supply: On -Site Well L---' _ Community Public Evaluation By: Auger Boring L/ Pit Cut FACTORS 1 2 3 4 Landscape position .L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH f" Texture groupe 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 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: G 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 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 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 27Z .62 _ D. 8:113-758 `;o\ -p 0 172-433 p.t� 0. point < Totot 2, 362. 63Iron lound tt\ \ c S 04°- 39 �` t. 182.63' W --_ S 36-28-45"E new line S54°-27 45� goo bT pomtx - ,on plocetl 176.61 1, 180.00 124.34. a otol. 659.00 S00°-55 -35' W \� oomt 130.52 °Ovp1QCV498.48 trop found 30 \n rood C 1 P 0.6 27 .10 N \ S E3°- 56'- 30 ACRU F,�S CD � \ `�'\ w N •N ; 243.42 _ P u, D 0 0 $ D!°- 40 E —�" Iron p1O: d — 14. OO ACRES �S DOmt ►,321.45 + ro ��> `ooa S 58°-07 - t point now line "01 r \\� In 59.4 .Iron p occd —F � XN r - .. al I F 3o'seosement 16.000 ARES \.\ S 520- ov ! R ---N040_?9' Ee—w---- -- —T__— — .on loced oto1 1 ,n 936.65'—n—rrtevoe 515.90 10.62"ACRES <7 11 oloctd — — — — 373.48' line 40 W piocc7 r�i ! E CO l w 10.000 qC �; to ° _ 40 E_ ._ new line M RES c N r1i ; S 01 Iron Placed CD° z 863.36 1.471.49 21.80 ran ploced co i iron tounatie r 7"L 01°_DB'-15'1.493.28' r -� >- fou loon. v W c to o� ' and ry /40_0 8Q 701 1 \� S 85°- !6'- 45' W ! J pfl ~ ") A ^ c eo, a �`5 E 1 200.9 8 tD to 10.628 ACMES 1 " 2' Iron placed i - . m a „I pieced 2g, Ge \F 484. 12' iron N 00°- 31'- 25 W Placed — !FA =141.805 ACRES (by d.m.d..) a'S ,y0 Fj.5�a0"5 \a � 6*• block OOk fence cornet PARCi _ I PAUL Y 'ENDRIX D. B. 75-281