131 Shady Grove Lane Lot 19_: .... r. .. .....n'N r:1.. t•lY\I"F4VYrY19FT <.{ > .y ...Q..1, _! R ... i. _-yy'Y�...
AU; ORjZATION NOi 0946 DAVIE COUNTY HEALTH DEPARTMENT
I Environmental Health Section ' PROPERTY INFORMATION
Permrtteeyc .. P.O. Box 848'
Name Mocksville, NC 27028 Subdivision Name
Phone #: 704-634-8760
DireC[eb s to property5 Section % Lot:
AUTHORIZATION FOR .
WASTEWATER Tax Office PIN:#.1
SYSTEM CONSTRUCTION
�t
Y,/ y.
Road Name: 0. GYOip' D�
**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)
f / Y ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS �r
ENVIRONMENTAL HEALtHSPECIALIST DATE ISSUED , -
{.
..1111 \�.. .p.J'�'
DAVIE COUNTY HEALTH DEPARTMENT
d, IMPROVEMENT AND OPERATION PtRMITS PROPERTY INFORMATION
„Pe&Mtteeis
Name frr ._ftfAe�/
Subdivision Nam --
A
Drrect�ons to property; r,' Section. Lot:14
IM0116VEMENT
j
t; PERMIT Tax Office PINI#�-
Road Name: ,'--5
**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
constructionlmstallatioii 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) i
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IFtSITE
+ta ^c w fi... ✓' /�' J i ,�j" PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATERS {
ENVIRONMENTAL HEAL SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE g )
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS +? - # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE - # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE Yes or No
-LOT SIZE � TYPE. WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD). -1.1,9 NEW SITE. REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE Odd GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH LINEAR FT, rod'
OTHER .. .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
DCHD 05/96 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
t Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760
1�
****IMPORTANT"" THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed LNz1S VomycetL Contact Person t'HR/S •Tomx[SdN
Mailing Addressl-//4 w. edc, AIWV 1-4 Home Phone 9/0-249-224`
City/State/Zip /.CrIA11-7-6^1�, Min 27 295 Business Phone 9/0 - 7 2.7 - 20 A L it
2. Name on Permit/ATC if Different than Above A1/4
Mailing Address City/State/Zip d1A
3. Application For: f t-rSite Evaluation [ ] Improvement Permit & ATC [ ] Both
4. System to Serve: [q -House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People_2_ # Bedrooms 3 # Bathrooms 2 . S [✓]'Dishwasher [&-] Garbage Disposal
L%q-washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type W—A # People #Sinks
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [vMounty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes
If yes, what type? i,/Ia
# Commodes
[y No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***.l[TI ATOF THE PROPERTY MUST BE
SUBMITTED WITH S APPLICATION.
Property Dimensions:
'WRITE DIRECTIONS (from ocksville) TO PROPERTY:
Tax Office PIN: # 5'799 - 34 9941 4PAsT ZErr ovm NwY 601
Property Address: Road Name SN.9cy (&ROUE Z.v. oNTo oDEZe Mye£s ,ZD,
City/Zip A/ aAN[e' _&e 2 700& ; / sT.2D, on) /FFT .16 SHNDy G2o vE .
If in Subdivision provide information, as follows: GoT /!2 /.s 2 N G o'T vAt i-
6-,-r-Name: ✓HADY bevve
Section: Lot#: /9
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 emets7bPoRA K. Toauso,v to conduct all testing procedures as necessary to determine the site suitability.
DATE 07•/x_`7 SIGNATUREial
Revised DCHD (06-96)
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN: -
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section IP/
Soil/Site Evaluation /
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cl__� Cut
FACTORS ! 2 3 4
Landscape position
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH ''z/
Texture rou
Consistence
Structure /1
Mineralogy-!
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture rou
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 S7Shoulder 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.ry 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
Saprolile - 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(suilable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/fl2
DCHD(01-901