139 White Dove Way Lot 5-� 'AUttiORIZATION NO. 0791 DAVIE COUNTY HEALTH DEPARTMENT
i Environmental Health Section PROPERTY INFORMATION
Per,;uttee's.• P.O. Boz 848 (�
Name:Mocksville, NC 27028 Subdivision Name:
rr ` Phone #: 704-634-8760
Directions to property: t ->�� +\ Section: Lot:
AUTHORIZATION FOR t ^�
WASTEWATER Tax Office PIN:# J f ab _ -� 4 _ f q -7:�
SYSTEM CONSTRUCTION
a s; Road Name: L� �� W 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 Fonn/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.
Is VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
DAVE COUNTY HEALTH DEPARTMENT . ;>
IMPROVEMENT AND.OPERATION PERMITS PROPERTY INFORMATION
N ; +�sion Name: �' L
directions Io property: LAA '1'� - :.'? � I's
-� Section: Lot:
�• _. • PFU HT 'Tax Office PIN:# s 'L,:io S- 3
Road Name: 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
constiucdonhnstallation of:* system or the issuance of a building permit
(In compliance .with Article 11 of G.R., Chapter 00A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) !
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION:IF SfI r
PLANS OR THE INTENDED USE CHANGE YOUR'WASTEWATER .
ENVIRONMENTAL HEALTH SPECIALIST DATE'ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM. +'
RESIDENTIAL.SPECiFICAT�ION: BUILDING TYPE-SOL • '# BEDROOMS 4 # BATHS 3 # OCCUPANTS __ GARBAGE DISPOSAL Ye or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDbSTRIAL WASTE: Yes or'No
• . LOT SIZE • • 59 Ws"TYPE WATER SUPPLY W 'DESIGN WASTEWATER FLOW (GPD) bd NEW SITE 110,
REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE MO GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH 1� LINEAR FT..J O
OI,HIIt dAtk
r _
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
" 'A -
**CONTACT A.REPRESENTA F THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF TIES SYSTEM
: BETWEEN 8:30 - 9:30 A.M. OR 1:00 -1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 6348760.
OPERATION PERMIT ��
SYSTEM INSTALLED B
ae
IP
Fk
AUTHORIZATION NO!�! OPERATION PERMIT BY: �a\.DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
ur
WITH ARTICLE 11 OFG:S. CHAPTER 130A, SECTION :1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME:
DCIn) 03/96 (Revised) .. .
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC=
Davie County Health Department
Environmental Health Section
P. O. Box 848`
i
Mocksville NC 27028
AM — 81997
704 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE L--1ti PROCESSED NLE i.
ALL THE REQUIRED UIRED INFORMATION IS PROV _
1. Name to be Billed :3664 Mardic- wy-k Contact Person
Mailing Address a b ag 4 -LA a of Home Phone
City/State/Zip r; h U B.IJd 1, /I C a 7o a o Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation Improvem.AntPermit & ATC ❑ Both
4. System to Serve: 8 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People CO- # Bedrooms # Bathrooms 3
Dishwasher Garbage Disposal Washing Machine �Basement/Plumbing C3Basement/No Plumbing
6. /, If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
7
8
If Foodservice: # Seats Estimated Water Usage (gallons per day)
Type of water supply: ❑ County/CityWe 1
Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes 4 No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: y(box I5OX 3DOY-! 1bX X 9.56 >-tty IR WRITE DIRECTIONS (from
t Mocksville) TO PROPERTY:
Tax Office PIN: # 5g a0 - —� - 7q73 1
I�� It t c 601 /f/ iccs� �y�s '
Property Address: Road Name Uft 116AJ a - 'phi S YV��- 1
City/Zipoc�C
1
If in Subdivision provide information, as follows: 1
1
Name: &)Ue- Apses 1
1
Section: Lot #: 1
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 a& � j ar e - Aggg to conduct all testing procedures
as necessary to determine the site suitability.
DATE �60/qq SIGNATURE
Revised DCHD (06-96)
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APPROVED TRICT E ER ..... .... ... da 7-30 as amended Witness my original lognatwe. regiauation number and sea[ this 14 &1. this
(Seal or Stamp ) Registration Numbsir' L-LI30 seal or Stamp
day of A.D. 19 -1.7 ...........
DATE. .. ... .... .... . ... . .......................... Surveyor
DIRECTOR OF PLANNING so
day Of .......................... 19
Notary PuNic
My commission expires .. �
POND
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3.590 ACRES
CA
UNE BEARING WSTk,
1.051 ACRES In r- Ll N 87'29'02' W 71.7:
L2 S 79'39'00* W 82.40.
L3 S 72.29*35' W 94.1
L4 S 6418'49' W 77.2
U L5 S 60'19'31' W 75.2L
its UZ
N 29.59 00' W NCC SS CASEMENT S 35*271321 W
81.30 OF 59.58
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2*21'56' E
N 28*00'43' W S 69.26
72.91
N 26.16' 57' W
50.00
7
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4.678 ACRES
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1.076 ACRE
N 22.20'18' w
_ • ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE e0,92-4,2
Community
Public
Evaluation By: Auger Boring Pit `___ Cut
FACTORS
1
2 3 4
Landscape position
Slope Z
2
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
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
r-7777
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-901
EVALUATED BY: _/v ll
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 :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
Mineraloicy
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