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224 White Dove Way Lot 11AUTHO .. ,. RWATION.NO. 1 1 0 6 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permiciee'sP.O. Box 84$ Name: �.Mocksville, NC 27028 Subdivision Name:��f:`�� r'��,► "-; ,/.�,, Directions to property: l�"r Yr 4,46r,Phone #: 704-634-8760 Section: Lot: � AUTHORIZATION FOR WASTEWATER Tax Office PIN:# . r SYSTEM CONSTRUCTION Road Name:ip: **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, I l 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 SPE IALIST DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT ANDPIERATION PERMITS PROPERTY INFORMATION Perlt►ittee�'s q Subdivision Namer,,-- Directions t6 property:� Section: ,^- Lot: ZZ f 4 IMPROVEMENT. PERMIT Tax Office PIN:# N -��' - r' ✓"r - fr ��: '?) ' Road Name r' �,', • 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 ., PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMrr BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE AI # BEDROOMS � # BATHS,1� -T- # OCCUPANTS , 7 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY Alt.° DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE -h-6.Z-)GAL. PUMP TANK GAL. , TRENCH WIDTH � A ROCK DEPTH �J -fLINEAR Fr. 5/� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 17s' **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 INSTALLED BY: J'j0 l AUTHORIZATION NO. j� D-� OPERATION PERMIT BY: /�L�fi[ 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) ¢ .�'.:^']Vr'll"f�i�j„..•1�i'1�-}ItX.f' ”-��I.SlrY'.�yi'•-Y`f DAME COUNTY HES TH DEPARTMENT _.IMPROVEMENT AND RATION PERMITS PROPERTY INFORMATIONAD . Y N,gMe'y& Subdivision Name ,r4.,►. f * �, `Section 9 h IIVIPRO ,°Y` l �fJ. PERMIT Tax Office PIN:#SV*4. _ - �•Road Name: &>�' . �. dip: **NOTE** This Improvement Permit DOES NOT authorize the on 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 constnictiori/uistallation of a system or the"issllance of a building permit - (In compliancewith Article 11 of G.S..Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THLS PERIVHT IS SUBJECT TO REVOCATION IF SITE t rA } PLAN&ORTHE INTENDED USE CHANGE. YOUR WASTEWATER v SYSTEM CONTRACTOR MUST SEE THLS. PERNIIT. BEFURE ENVIRONMENTAL'HEALTH SPECIALIST :.DATE ISS, . . INSTALLING. THE SYSTEM. f RESIDENTIAL SPECIFICATION:.BUILDING TYPE# BEDROOMS r ` _ _ # BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACIL rY TYPE # PEOPLE # PEOPLEJSHIFT #SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE .TYPE WATER SUPPLY- DESIGN WASTEWATER FLOW (GPD) NEW SrTE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE . MPGAI 4 PUMP TANK - -GAL.. TRENCH WIDTH _ ROCK DEPTH �� LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: ' **CONTACr.A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 100 -'1;30 P.M. ON THE DAY OF INSTALLATION: TELEPHONE # IS (704) 634-8760., wnu y�no �ncv�wa) . 4 � ,APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848 j Mocksville, NC 27028 OCT 1 p 1997 (704) 634-8760 UI ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE1 THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed -��i "�X 10. 1 Contact Person + 74LL Mailing Address_ Home Phone —�; 3�-- %7f � City/State/Zip , t ('� _� (.��SCSC� /V '�1� Business Phone Znq " dJ " Jr (, 1 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [ ] Site Evaluation City/State/Zip [ ] Improvement Permit & ATC Both 4. System to Serve: V House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms-- # Bathrooms; (x] 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 KWell [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes �] No If yes, what type? Fh!'E EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***XAIMAIT OF THE PROPERTY MUST BE P� G� - 3 - - t-(., 0 1 SUBMITTED WITH THIS APPLICATION. Property Dimensions: WRIIDIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: #�n - - cosLI Property Address: Road P�ame LzJ Cit/Zi Y P A -I 4: , Z,Cy # �r P ' If in Subdivision provide information, as follows: — Name: IN Qcu'-'o ' Section: Lot #: 't I 12,k- LVF -',L t 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 of the Davie by DATE SIG Revised DCHD (06-96) Health Department to enter upon above described property located in Davie County and owned all THIS AREA AIAJ $E USEI) FOR MZAIVINC YOUR SITE PLAN: to determine the site suitability. TUTZMW SURPMM COMPANY 127 LIBERTY CHURCH ROAD "MMILLE, K Q 27028 (704) 492-3616 REVISED: JULY 21, 1997 300 150 0 300 600 900 SCALE IN FEET JOB NULOM 24198-1 DAVIE COUNTY HEALTH DEPARTMENT r - Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME //moi �� DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring Y Pit ' ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L, ,L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH A10 P Texture group' G Consistence Structure lC ,6-G Mineralogy�J 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 V SITE CLASSIFICATION: 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 ■EEEME■ ■■■EMM■ ■■E■■■■ ■M■■M■■ ■E■■MM■ ■RNMEM■ ■UME■■■ ■v■■ME■ ■■MEMEMMEMM■■■ ■ME■■■MME■M■M■ ■EM■MME■MMEM■■ ■■MEMEM■■EMEM■ ■EM■MEM■■■EME■ ■EMEMEMME■EME■ ■■M■■MME■■M■■■ ■EMMEMEMMMMME■ ■EM■EME■■EMEM■ ■EMEMEMEMEMEM■ ■EM■■EME■■MME■ ■EMEMEM■MMMEM■ ■■EMMEE■EMM■■■ ■■MEM■MEMEM■■■ ■■M■M■EME■EM■■ ■MM■■MM■■■MMM■ ■EMEME■MM■MEM■ ■EMMEME■■E■■M■ ■E■■M■M■■MEM■■ ■EM■■E■M■■MME■ ■■■M■■ME■MEMM■ ■■MMEM■■EMM■■■ ■EMM■■E■■■M■M■ ■E■■MME■■MM■■■ ■■■■■■■■■■■■■■ ■■■■■■■■SIS\\■■ ■■■■■EMI■■■■■■ ■E■ ■o■ ■o■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■E■■■■■■ ■M■MEM■■ ■M■MMEM■ ■EMEMEM■ ■ESMMEM■ ■■M■■ME■ ■MMEM■E■ ■ ■ ■■M■o■ Monson ■EMEM■ ■EMEM■ ■■E■■■ ■EME■■ ■ ■M■■MEM■ ■M■E■M■■ ■EM■MME■ ■MMEMM■■ ■ME■MME■ ■M■MEME■ ■M■E■M■■ ■M■■ME■■ ■■■■MMES ■M■■EME■ ■E■■MM■■ ■E■E■M■■ ■■■EME■■ ■ME■■M■■ ■M■MEM■■ ■M■■MME■ ■M■■MEM■ ■■■n■■■■■■ ■■■n■■■n■■ ■■■■■■■■M■ ■■■■■■■■E■ ■EMEMM■■ ■M■■ME■■ ■E■■ME■■ ■■■E■■E■ ■■M■■EM■ ■M■■M■■■ ■ ■E■E■M■■M■ ■■E■M■■ME■ ■■■MEMS■M■ ■E■EMEM■■■ ■Es■■M■■M■ ■E■■M■EME■ MEMEMEMEME ■E■M■M■■M■ ■E■■M■ME■■ ■■MEM■MME■ ■■M■■M■ME■ ■■■