2491 Hwy 801 S Lot 21AUTHORIA«TI�ON NO 1 1 9 '. DAVIE C
%nvironmental
UNTY HEALTH DEPARTMENT
Health Section PROPERTY, INFORMATION
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Permittee s /
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P O! Box 848
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Name dlsl
Mocksville; NC 27028 Subd[viston Name: •
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Directions to property; /D7f Nan ' " .
Phone. #. 336-751-8760
Lot:
Section: Lo
1
THASTEW ION FOR WATER Tax Office PIN:#.-
SYS TEM CONSTRUCTION
,'. Road Name:1S 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 Form/Authorization Number should be presented to the Davie County Building Inspections
Office whenapplying for Building Permits. .
(Incompliance with Article I 1 of G.S: Chapter 130A• Wastewater. Systems,`Section .1900Sewage Treatment and Disposal Systems) .
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9
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A'PERIOD OF FIVE YEARS.
;: ENVIRONMENTAL HEALTH SPECIALIST " : DATE ISSUED
r***NOTICE*** TIBS PEP.NM IS SUMJECT TO REVOCATION jF SITE
PLANS OR THE INTENDED USE CHANGE..YOURWASTEWATER
SYSTEM,CONTRACTOR MUST SEE THIS PERMIT BEFORE t.-
ENVIRONMENTAL HEALTH SPECIA I T DATE ISSUED INSTALLING THE SYSTEM.
,RESIDENTIAL SPECIFICATION: BUILDING TYPE . S BEDROOMS � . N BATHS e%. S' k OCCUPANTS _ GARBAGE DISPOSAL> Yes or No ..
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r- APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
�' � 6 � � � vt unty Health Department
D
nmental Health Section
P.O. Box 848 NEW PHONE NUMBER:
A. - 8 1998 1 cksville, NC 27028 EFFECTIVE MARCH 22, 1998
(704) 634-8760 336 751-8760
.�...ia,Ill .. ..
****IMPORTANT ""`ITHI ATION CANNOT BE PROCESSED UNLESS ALL
T'' II 4 t -I' M[THE REQUIRED INFORMATION IS PROVIDED. \ /
1. NametobeBilledbVeA OP Dn5+nt[ m I nCContact Person V `%f
Mailing AddressnnD, O>C a LJa (7 /I Home Phone r� - p�-/
City/State/Zip `� tri VO-nr'c,_QC a-1 OU lO Business Phone CR R - b Z� 5;--0
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ to Evaluation [i] Improvement Permit & ATC
[ ] Both
4. System to Serve: P111cuse [ ] Mobile Home [ ] Business [ j Industry [ ] Other
5. If Residence: # People # Bedrooms 3 # Bathroomse' z [ 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: ( ounty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ 9 -No
If yes, what type?
-.1 - - EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***,YMQM OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: a2 /a2 X is -4 X /74 X /77 WRITE DIRECTIONS (from Mocksvillte�) TO PROPERTY:
Tax Office PIN: # 5-1B 9 - z AAi % �n Z �o 1o4 —6 -k bJ lj 8D 1/ — I r-t�-�- Cell . b 0 1
Property Address: Road Name -1lm it F01 �t ,4-h .':,npp
1 t�,�rn i [ n .
City/ZipAAgm, CG oR--) ;lOrnet of �DI f baL 11 �tuUS PA
If in Subdivision provide information,s follows:
Name: ��bar{L Graz 1L)Pmcn+- ;
Section: Lot#: a '.
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
Re�prJ�sentative�of the Davie County Health Department to enter upon above described property located in Davie County and owned
by V (]flier Cam*
tXI * /l� :rtxnem CIMS . to c9J uct all testing �rocedu as ne ary to determine the site suitability.
DATE QB_ SIGNATURE�n(�tb
Revised DCHD (06-96) U
THIS AREA MAY BE USED FOR DRAWING YOUR:SITE PLAN:
�607� �l
Xv, 70
/ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
r ` Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIII.TY
DATE EVALUATED
a/
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public !/
Evaluation By: Auger Boring Pit t/ Cut
FACTORS
1
2 3 4
Landscape position
Slope S
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
O/ -
Texture group'
C
Consistence.
Structure
S /L
51///
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
SITE CLASSIFICATION: r/�S EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: OTHERS) 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 •Aay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
Moist
VFR-Ve-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
SC -Single grain M -Massive CR -Crumb CR -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(suilable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD (01-901