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215 Shady Grove Lane Lot 12AlYTHOR;IZATION NO:0718' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Pemuttee's' J. !kH/Y � P.O. Box 848 Name - Mocksville, NC 27028 Subdivision Name p Phone #: 704,634-8760 Directions to property. / Section: Lot: AUTHORIZATION FOR - WASTEWATER :' - Tax Office PIN 3(0 . _ . SYSTEM CONSTRUCTION -` - - - RoadName:--5' !J l Lip k6 **NOTE** This Authorization for Wastewater System Constriction, MUST BE ISSUED by the Davie County. Environmental Health Section prior to issuance of any Building Permits. This Fomi/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. On compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ' '**NOTICE*** THIS AUTHORIZATIONFORWASTEWATERCONSTRUCTION r..4�� IS VALID FOR APERIOD.OF FIVE YEARS. - ENVIRONMENTAL HEALTH ECIALIST'. DATE ISSUED - a 1-k ,.- ��: ".r"'-'rr rrw .--�•..,> sw�•+,;rn�,,"p'•h.;'1:s�.a;;t;;�.�¢.krr,s..�•z;,l..y;-,.w �,fl.,c.-'ar :, .r„,,,,. __... .. �i/7C0 .. ^ DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS, PROPERTY INFORMATION Permtttee'sy� Name - J' Subdivision Name Directions. to property: Ei fr/"Ot Section: % Lot: /9 IMPROVEMENT PERMIT . Tax Office PIN:/#• k' Road Name. -al ClN f 41riip `Z� **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 constructiontinstallation of a system or the issuance of a building perms (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) / ***NOTICE*** THIS PERMIT IS SUBJECT TOJREVOCATIONIFSITE L 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_ # BATHS a # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE - # PEOPLE _ # PEOPLE/SHIFT # SEATS _'INDUSTRIAL WASTE:: Yes or No LOT SIZE•�..[Af � TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) NEW SITE � REPAIR SITE -SYSTEM SPECIFICATIONS: TANK SIZE e:: V GAL. PUMP TANK GAL.. TRENCH WIDTH, ROCK DEPTH LINEAR FT. O G OTHER' _ REQUIRED SITE MODIFICATIONS/CONDITIONS: - IMPROVEMENT PERMIT LAYOUT ( **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: i Ca � no AUTHORIZATION NO.M OPERATION PERMIT BY: 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 05196 (Revised) q. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC V4' '- .� Davie County Health Department S' Environmental Health Section D L5 V P.O. Box 848 Mocksville, NC 27028 MR _ 31997 M (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCE SEED UM6�� THE REQUIRED INFORMATION IS PROVIDED. i . 1. Name to be Billed n7777F a n e t"'o n s/ Mailing Address 'gel '.7 .eA lee W ecu /lei City/State/Zip ///C 2702 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person oseb // /&;� d?,Y+C� Af Home Phone �% 9 - `� b^ / s Business Phone 9 �ac�en_l9/oil/'i./,PL7( `l"7_97 City/State/Zip 3. Application For: 130 Site Evaluation [vf Improvement Permit & ATC 61'Both 4. System to Serve: A House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: .# People_ #Bedrooms # BathroomsDishwasher[ ] Garbage Disposal 'k,] 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: [4 County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes, [J No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT **5ok3 OF THE PROPERTY MUST BE yyy Se ge.Ad ed SUBMITTED WITH�H�S APPLICATION. .L/ ad 1'' WRITE DIRECTIONS (fro Mocksville Property Dimensions: � ) TO PROPERTY: Tax Office PIN: # - 3 6 1 Q 70 2-O / Sdu /1i —27,- Property v aProperty Address: Road Name Z0 % A -5 a-o� 6:ye& e AJZe-,�f'T o �l City/Zip wr, ✓7 %vr n .Ce f 7-. /,v If in Subdivision provide information, as follows: Gro v e %% u e /oo� Name: �/Ja-och (Thoue- '/eae� Section: - Lot#: /. .7T 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 DATE 3 Revised DCRD (06-96) Health Department to enter upon above described property located in Davie County and owned all THIS AREA MAY BE USED FOR DRAWING YOUI? SITE PLAN: 3a. determine the site suitability. y • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_--/_LOT12- Soil/Site Evaluation APPLICANT'S NAME fain/� PROPOSED FACILITY SUBDIVISION --- DATE EVALUATED PROPERTY SIZE 3��a ROAD NAME Water Supply: Evaluation By: On -Site Well Auger Boring L/ Community Pit Public Cut -Z— LSlo Slope e % 12 HORIZON I DEPTH FACTORS 1 2 3 4 5 6 7 Landscape position -Z— LSlo Slope e % 12 HORIZON I DEPTH Texture group Consistence Structure Mineralogy- HORIZON II DEPTH f .: Texture groupL G Consistence Structure Mineralogyl.' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION Pj- LONG-TERM ACCEPTANCE RATE I V I c SITE CLASSIFICATION: � .2 EVALUATION BY: A11 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 clay loam SII. -'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 OR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 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 (01M)