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108 White Dove Way Lot 2-3,,...; —z ,o.x.. i;z k._,. -._. ,., ;:..i W.:: .. ...1..�.., :'r r•.t•.�:.-.....a., 3�: ,yt'-.. �;;i e,eb�v:j.,. •. .. :a'X: y�.• 5.. :. ,r-� AUTHORIZATION NO: ( DAVIE C , UNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee'sgp + ` P.O. Box 848 f/ s Name: �,�� Mocksville, NC 27028 Subdivision Name: v .1f`6 Phone # 336-751-8760 . Directions to property: g2.2C11111 ZL ✓ % i Section: 4f Lot: &44' �� AUTHORIZATION FOR /CvWASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION -tel Road Name: to 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) (, ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION T 7i% �� • �� "7 It, J, IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED r— { t'.i a ^. r• ` �: ..IT- Ic .-""`y.Rvr+—...rm""•"'rS • . ' Y , ' DA ,VIE C DUNTY.HEALTH. DEPARTMENT iMPRO , EMENT. AND OPERATION; PERMITS PROPERTY INFORMATION ,► " Name. •s:' t vision Name: -••;.'Av - - Directions to property. . Section: Lot: A - _ . ' j `IIVIPROVF.INF1�1'I' t ��vJ PERMIT .. Tax Office PIN:#�aZQ,- .Road Nine' Zip: *NOT'E** Ti is Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any'wastewater system. An,. ti AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained,from'this Department prior to the .const<uciion/udstallation of a;system or, lie issuance of a,building permit.. On comphance with Article 11 of G.S,,Chapter 130A, Wastewater Systems. Section .1900 Sewage Treatment and Disposal Systems) t ti ' NOTICE**' THIS PERNIIT IS SUBJEcT TO REVOCAnww SITE PLANS OR:THE INTENDED USE CHANGE. YOUR WASTEWATER - SYSTEM CONTRACTOR MUST SEE Tms PERMTr BEFORE F.NVIRO AL HEALT SPECIALIST. DATE ISSUED { l j INSTALLING THE SYSTEM. i•, RESIDENTIAL SPECIFICATION: BUILDING TYPE /y' ' # BEDROOMS � # BATHS � # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIssAL SPECIFICATION: -FACILITY TYPE #'PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL. WASTE: Yes _ or No I LOT SEZE . HYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �61i NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SUEZ—&—dGAL; . PUMP TANK , -CAL. TRENCH WIDTH 36 ROCK DEPTH ✓� LINEAR Fr. T iii! OTHER t REQUIRED SITE MODIFICATIONS/CONDITIONS: ' IMPROVEMENT PERMIT LAYOUT IAPPWM .6�iL.IJEY't' FIL RIMIS). IV 6*� "'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 N0. 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 DISPUSAt SYSTEMS"; BUT SHALL IN NO WAY BETAKEN AS A .GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD'OF TIME: DCIm 05ft (Revised) APPUCA110N FOR SITE EVALUA11ON/IMPROVEMENT PERMIT A A Davie County Health Department D 0 M Environmental Healtfi SmWon P.O. Box 868/210 Hospital Street MR _ 4 1999Mockaville, NC 27028 �[ 1336) 751-8760 ***nWORTANT*** THIS APPLICATION CANNOT BLS PROCESSED UNLESS ALL --- - INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. name to be Billed 1 ACA t r n i Contact Person-S.4t�- Mailing Address S �► ri A I - some Phare 5136/ / blel City/state/LIP �D kS�i, C. / eGp Business Phone Z. name on Permit/AtC if Different than Above e Mailing Address Z/&%' L City/state/Sip 3. Application For: U Site Evaluation If Improvement Permit/ATC 0 Both s. system to service: House 0 Mobile Home 0 Business 0 Industry 0 Other s. If Residence: # People # Bedrooms # Bathrooms_ ZDishvasher 0 garbage Disposal a Mashing Machine "asement/Pimbing 0 Basement/no Plunbing 6. If Business/industry/other: specify type # People # sinks # Caamodes # shovers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Nater supply: County/City 0 well 0 Co=zunity s. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes "0 If yes, what type! ***IMPORTANT*** CLIENTS 11lUST cohfpLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either s PLAT or SITE PLAN MUST BESUBMITTED by the client with TMS APPLICATION. Property Dimensions: 323 #z $$2o -s3 -G BTl ,00a�� Tai Office PIN: # A3 3820 - sy- Looy/, Q037°'J Property Address: Road Name M 1/l City/Zip o kfu l I l e 4 1(J z?ozY If in a Subdivision provide information, as follows: Name: IAIA'Jy e G M Section: Block: Lot: d" . WRITE DIRECTIONS (from Mocksville) to PROPERTY: d I ✓Uo R 1 \ % m; /C Art� of 0_A_✓1l4- 6J. D& 4:., ht h; f, Oove bte r,ft /V I r 0 K R; Q Ll Date Property Flagged: This is to certify that the information provided is correct to the test 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 ani roponsible for all charges incurred frons 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 to conduct all testing procedures as necessary to determine the site suitabilit. . DATE 3� SIGNATURE tB: I i y C rf THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. TM / Revised DCHD (07/98) Invoice No. 51 q N 26'16'57' W 50.00 Z � Nw ✓s • o CJS 'c. o � • fc O„ x L � O N 22' 20'18' W 179.96 TOTAL . ti0' a9 W 0 � 65 300 0 i � �' e�� '. ✓ �� _ - � a'�04° �' 9< '• 6' -a� '' Q 1.076 ACRE %/ 4.678 ACRES 1p r °o o' �f . • � 63323 2 � Qom'. N r •. Ai 1.499 ACRES \ �� a�M �•. A7 •sl t '•. ✓�W bo gf e�e°`k exlsUnq ao WN dweion9 • •. 0' oar E.. �I '. ��' N. 1.147 ACRES N 21'56'47' W a, 314.09 TOTAL as 375,OS 78�1UlA0 '�f. • • • ' ' ' • � ✓ 1500' 00 S w' MAE ADY DDDR -AS P9, 93 'O \ 9G tit,1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section #,;2 / Soil/Site Evaluation NAME JN�� DATE EVALUATED :.. z ADDRESS PROPOSED FACIILTY PROPERTY SIZE '/1a�7./1 LOCATION OF SITE 45�01%_ _A �t.a�b— A k_ Water Supply: On -Site Well _ Community Public // Evaluation By: Auger Boring Pit r--, Cut ` HORIZON I DEPTH FACTORS 1 2 3 4 Landscape position Slope Z ` HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture groupG Consistence i Structure Mineralogy.•/ HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION f LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: /J EVALUATED BY: ��.// LONG-TERM ACCEPTANCE RATE: i Sl 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 fine 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 NAME ADDRESS PROPOSED FACIILTY DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation DATE EVALUATED / 21U 'l PROPERTY SIZE�P,2 /- LOCATION OF SITE _lP D1/✓ G/C t 1:4e_ b81U-r? Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit t✓ Cut FACTORS 1 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH O t Texture group 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: ,��/ 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- Vc.-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 Ilorizon 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