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107 Shady Grove Lane Lot 20-..i mpv q - de. o*/•-.! w+p-r .ns •nti ...- Tt' i r -gun s - AUTHOJ2IZATION NO:. 0827: ' DAME COUNTY HEALTH DEPARTMENT�� T� v Environmental Health Section PROPERTY, INFORMATION .Fee s'//// Boz 848 �(n Name. ,/� �r1Sa: P.O.Ivlocksville,'NC 27028. ` Subdivision Name. 'pJ1 Phone #: 704-634-8760 Directions to property: Section: Lot: AUTHORIZATION FOR WASTEWATER - ,Tax Office PIN:# SYSTEM CONSTRUCTION Road-0Name:G 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 FormuAuthorization 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 S AXI& IS VALID FOR PERIOD OF FIVE YEARS. . ENVIRONMENTAL IiEALTHS ECL4LIST DATEISSUED ,hrN DAVIE COUNTY HEALTH DEPARTMENT30 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Pe Subdivision Name: /Til Uro fiiame����j'S ' �h S;/;' .r7.�.9�i 1 Directions to property: "� �d Section: Lot: DAPROVEMENT PERMIT Tax Office PIN:# Road Name: /I Gi H ��'Zip �� **NOTE** This Improvement PermitDOES 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) �f ***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 PERMIT BEFORE _ INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS -P # BATHS # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE - # PEOPLE # PEOPLE/SKIFT _ # SEATS _ INDUSTRIAL WASTE: Yes or No LOT SIZE - �RCr TYPE WATER SUPPLYDESIGN WASTEWATER FLAW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE AgLGAL. PUMP TANK - GAL. TRENCH WIDTH ROCK DEPTH _Z -IL LINEAR FTZ�D REQUIRED SITE MODIFICATIONS/CONDITIONS: - **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) 6348760. OPERATION PERMIT SYSTEM INSTALLED BY:�q "" S AUTHORIZATION NO. OPERATION PERMIT BY: \ - DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I1 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 TAME. - DCHD 05/96(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT ] Davie County Health Department j r Environmental Health Section P.O. Box 848 Mocksville, NC 27028 j (704)634-8760 & ATC APR 2 4 1997 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE � REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed e✓S 1(VI.0 ON Contact Person Mailing Address 09- C Home Phone City/State/Zip C 6 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [ ] Site Evaluation City/State/Zip [Q1116provement Permit & ATC 4. System to Serve: rTHouse [ ] Mobile Home (] Business [ ] Industry 5. If Residence: # People # Bedrooms— L # Bathroom§� LJAVIaoshing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify # Showers # Urinals # Water Coolers [ ] Other [ ] Both ishwasher [ ] Garbage Disposal # People #Sinks # Commodes If Foodservice: # Seats '' Estimated Water Usage (gallons per day) "" 7. Type of water supply: county/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes' [I., If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** KTDA`tP:OF THE PROPERTY MUST BE y SUBMITTED WITH 7H,S APPLICATION. Property Dimensions: l + g °'L q a� WRITE DIR/ECTIpO/lNS (from fMocksville) TO PROPERTY: Tax Office PIN: # S% g� - _n,4 - ^^ li � I 1 �t Property Address: Road Name�O� WD/:/� city/Zip t/QnC�L .R/C22"6 ; _ «�. If in Subdivision provide information, as follows: v/1]2✓ I G! S Name: 9ad4 (72 V0 Lot #: 20 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 - o cond c --t all //testing procedures as necessary ito determine the site suitability. DATE SIGNATURE_ Revised DCHD (06-96) THIS AREA MAY BE USED FOP-DRAWINCGYOUR SITE PLAN: area In occoraance wun b.a. 4i ou LS_3513 _ nded.- Witness my hand and seal acknowledged the execution of the foregoing i trument. Witness my hand and. official. stamp, or se t is 7. P (f B L, � a of October, 1996 A.D. o '. y ®, v0 �Q S` �-� . ,� 2 ` day of..October, 1996. J 'moo . `�N otar i Ic �A® s �- iS7 C . GRA , /�� •` red L Sury or License No. ���rrr��u�a,e• I My commission F / fu� — ��sr�j'111„��,�� PARCEL 24, TAX MAP H-8 MARSHALL LEWIS SWARINGEN, JR. DB. 120 PG. 439 , ZONED R/A - t � l rEI P ' 207.00' 1Y 163.00 198.00 1 -� t Ai 0 141.50' N \ �, ' k 10 Z 1 \� • 00 O _26.1 '!� 2_0� _ —,=— L•� 01 227.3_ 2� OTA�_ m �oI � A4, _ = CSB - - 3. 50' L. A a- Q 65.3- C �r © _-- 7.325- - -- _- <c; 1 -_- _ - TOTAL__ ____-- -� +193.00' �\ �-� 34:32 1 =_— LO n: C-4 4/ 30W „v 00 Lo.in 1 k' 3 G.G�o 105.00 `c�, Z f 0•' � ' ,. oQ�'w S � 3� 50 C3 00 !Z7 co . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 14r' DATE EVALUATED ADDRESS PROPERTY SIZE / PROPOSED FACIILTY LOCATION OF SITE •SAadGrove Water Supply: On -Site Well _ Community .Public Evaluation BY: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 4 Slope % HORIZON I EPpp Texture rou Consistence Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralogy HORIZON III DEPTH S 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: AL 6� LONG-TERM ACCEPTANCE RATE: —__L_�_ 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 <:lsy 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(suilable), 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/f12 DCHD(01-901