The URL can be used to link to this page

137 Timber Creek Road Lot 4Ar .riORIZATION NO: Q 9 8 6 DAVIE COUNTY HEALTH DEPARTMENT { _ Environmental Health Section PROPERTY INFORMATION :tee's �j .� P.O. Box 848 Name Name: 'tiCJf(t �„ / , Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 Directions to property: �i .< << Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#r�f SYSTEM CONSTRUCTION j Road Name. A-11\ (21 U. f **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Sectionprior 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) �PECIALI ***NOTICE*** THIS AUTHORIZATION' FOR WASTEWATER CONSTRUCTION .IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTDATE ISSUED 00 ,...7:� Pl'Y.G DAVIE COUNTY HEALTH DEPARTMENT : IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permitiee's Name: _, A t"' f` -'; .:.�tlm� 77, Subdivision Name Directions to property: tr, �,%r/ ''r Section: ,f Lot:' r IMPROVEMENTPERMIT Tax Office PIN:# Road Name -"l 1 _, 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 (';' t rl r;• �� , .: c' lr' ,,/ '` 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 Zf # BEDROOMS —E # BATHS V # 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 v' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. 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 (704) 634-8760. OPERATION PERMIT Syc 4` waa, cAQ�p q`Ii-5i deef ��• AUTHORIZATION NO. SYSTEM INSTALLED BY: M 0 1R Y, i DATE: //-/z-9-7 "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 SECTION LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED %C % PROPOSED FACILITY PROPERTY SIZE SUBDIVISION �rrnbe!— free,- ROAD NAME Water Supply: On -Site Well Community Evaluation By: Auger Boring _ Pit [/ Public 6--l' Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % (d HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group1 Consistence �- Structure K 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 , S' SITE CLASSIFICATION: i �� , c k LONG-TERM ACCEPTANCE RATE: . 3 S— REMARKS: DCHD (01-90) EVALUATION 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 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 ■E■NE■ ■■■■m■ ■Em■S■ ■n.E■■ ■ ■■■■■ ■ENE■ MEMOS ■■N■■ ■ENE■ ■■N■■ ■ENE■ ■■N■■ ■■N■■ ■■o■■ ■ENE■ ■EN■■ ■ENE■ MEMOS .................... .................... .................... .................... .................... .................... .................... .................... ■■M■ SOME ■.■mono■■■■m■ ■■■EE■■NNOME■ ■Emm■mmmo■■m■ ■■N■■NEE■■■■■ ■■■■■m■■■m■m■ ■■■EE■■EENN■■ ■■■■U■■■■■■i ■EN■ mm■.m■ ■■■■■mo■■■m■■ ■■.■E■■n■■E■■ N■■■■■■■■■■.■ ■■■■■m■■■m■o■ ■■■mom■■■■m■■ ■■N■.■.NEEM. ■ommu■o■■m■■ MEMO ■O■■■■■ ■■■■■m■■mo■■■ ■.■..■■..■■■. ■E■■■■■N■n■N ■■■■■■■■■■K■■ ■o■■m■■mmo■■■ Nom■■m■■mm■■■ ■EN■■E■ ■..■.K■ ■o■■o■■ ■E■EME■ ■■■E■N■ ■mm■■m■ ■EN■■E■ ■.■■.m■ ■■E■■ ■Nn■N ■■NE■ ■■■N■ KEEN■ ■.■■■ ■■■E■ ■■N■■ NONE ■NE■ SEEN ■■.■ ■O■■ ■O■■ NONE ■ ■ .............................................................. ............................... ............................. .............................................................. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC M �,•: Davie County Health Department Environmental -Health Section P. O. Box 848 Mocksville, NC 27028 _ k (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed CIG �-/� f'-'- 2,Sd (� �O Contact Person : Mailing Address, (�ii.UE�- �i4✓�.Ci Home Phone City/State/Zip //!L)C,&St//4-t...,E ILJ• C Business Phone 9`7,-22 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit & ATC 4. Sys :m to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other ❑ Both 5. If Residence: # People # Bedrooms # Bathrooms Q: -Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Ru.siness/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 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes ❑ No PROPERTY INFOf RMATION.REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST I.., SUBMITTED WITH TITS APPLICATION. . Property Dimensions: WRITE DIRECTIONS (from Mo svleTO PROPERTY. 4�.%Tax Office 7TH Property Address: Road Named nn 1 6i'4 x) G. �U3 A?o City/Zip H0 6.4 x) C- .2 700 1 If in S-uouivision provide information, as follows: �� 1 Name: (..,nee k 1 1 G'2v PG&rtJ 0 iJ Section: Lot #• 1 � L� 7 -- This 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 ,� ��'2�N�� andownedwliy/'�l �2�./J -�% � to conduct all testing p �ocedures as necessary to determine the site suitability. DATE SIGNAT".6; i zb-41� Revised DCHD (06-96)