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491 Madison Road Lot 15j'+ ) a`,'7 ..+C'-•f""-,F; 4••r: P+">'Y1 oc •a,•p:a rr • n`..+YF d;"'r 'i" .,�. - _ �j'' _ AiL�7�ORIZATION N - l 07 0DAVIE COUNTY HEALTH DEPARTMENT Environmental, Health Section ,PROPERTY INFORMATION Pest s. P.O. �% /� ' Box 848 [ Nanie. " ( J� C Mocksville;NC 27028 Subdivision Name: !J/00 Phone # 704-634 8760 Directions to property:. Gi' P c Section: Lot j } AUTHORIZATION FOR �� ��1//,7✓r" �('�� WASTEWATER Tax Office PIN:# 7of f SYSTEM CONSTRUCTION �9�7 Road Name: l9/Sari Zip 7aa$ **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 Officewhen applying for Building Pemdts. (In compliance with Article I I of G.& Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatmentand Disposal Systems) ,f �J *,**NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION U /w % i -: - IS VALID FORA PERIOD OF FIVE YEARS, - .ENVIRONME ALHEAL SPECIALIST--'.r DATEISSUED '''` tN4Z Lions to proptrty - _I- , 0, 1 **NOTE*'�-This Improvemeni AUTHORIZATIC construction/instal (In compliance with Article 11 i,-. 1 , , V, F70, DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Subdivision Name: Section Lot: IMPROVEMENT --PERMIT Tax Offic'6 PIN:# Road Name: /-I zip: 1ennitDOESNOTauthorize the construction or installation of aseptic tankssystern or any wastewater system. An i FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the don of a system or the issuance of a building permit. f G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment aind Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ENVIRONMENTAL HEAL r DATE ISSUED INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE eoj4ra # PEOPLE— # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE z2� TYPE W SUPPLY e4d 7TER DESIGN WASTEWATER FLOW (GPD) NEW SITE 1�1� REPAIR SITE A A� N TK& SPECIFICATIONS: S:, SYSTEM SPECIFIC - GAL. PUMP TANK ---GAL. TRENCH WIDTH —�6' ROCK DEPTH 2eLINEAkFr." REQULREO.SrrE MODIFICAITONS/CON impRovErAENT PERMIT LAYOUT ri 7,9.11 r 'i°S7or- I kwk *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. I OPERATION PERMIT SYSTEM INSTALLED BY: FAAIPY Mtzrx StlW104-S- L,—Ji x vaup -Tv 14ILL AUTHORIZATION NO. Wf) OPERATION PERMIT BY: 4� A -DATE lahg "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY M DESCRIBEDALOVE HAS BEEN INSTALLED IN COMPLIANCE... Y WITH ARTICLE 11 OFO.S.CHAPTER 130A, SECTION .1900 "SEWAGE TRFAWUAND DISPOSAL SYSTEMS"; BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revise4)"e. 0:1, i APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department cam! Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 1 I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. (.t 6O 1. Name to be Billed 1<701f-- L'�/©/2 Contact Person / Mailing Address 06 (7fdc�l �� sySf/n�/ Home Phone 41�) T City/State/Zip &Cla ��C ���8 Business Phone 2. Name on Permit/ATC if Different than Above 9e9�7F Mailing Address S qe F City/State/Zip 3. Application For: Site Evaluation Improvement Permit & ATC [ ] Bottht 4. System to Serve: [ ] House [ ] Mobile Home in Business ( [ ] Industry [ ] Other /� v n- 5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal [ ] Washing Machine [ ] Basemme�nt/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type,& V ClbTL # People%527 #Sinks/ 14 # Commodes # Showers l # Urinals_ # Water CoolersSY�t° ° ' If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: W County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes Os No If yes, what type? PROPERTY BQFO ATION REQUIRED: *** IMPORTANT *** SOF THE PROPERTY MUST BE �+ rI SUBMITTED WITH APPLICATION. Property Dimensions: ��/gc TO /!1A/'Aed 0 021 Ile WRITE DHZECTIONS (from ocksville) TO PROPERTY: Tax Office PIN: # s�a9 _ 7! L Property Address: Road NameCnrNer //4J%2(*✓ *di/j� WA t i)d & /'C �-'to /K city/zip *CksufI/G //� If in Subdivision provide information, as follows: , /d A &2 Ile Name: If Orrf,49S) cc Section: Lot.#: �/1� �e/il/1/S l 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 DATE U / Revised DCHD (06-96) THIS AREA MAY BE USEb FOR bRAWINy JOUR SITE PLAN: procedures as necessary to determine the site suitability. pyIelh!r a APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT � Davie County Health Department Environmental MocP. 0'�I, Box 665 27028 Healtht1on 1. Application/Permit Requested By Al "'9A �1 , Mailing Address u�Uda� 4p/ — AK"7 2S ///OG C ri •, /LC Home Phone �%� `��%��)� Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision 5 Section 1 Lot # 4 ' No. of People ,d�� -//FY' No. of Bedrooms No. of Bathrooms Dwelling Dimensions 6, If business, industry, place of public assembly, other Specify type No, of People Served No. of Commodes No. of Lavatories No. of Showers 7. Type of water supply: D, -Public No. of Sinks No, of Urinals No. of Water Coolers Water Usage Figures ❑ Private 8. Property Dimensions Sewage Disposal Contractor ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expanslon of the facility this sytem Is Intended to serve? ❑ Yes . ❑ No If yes, what type? ❑ Community. L=ion, ements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to if site plans or the intended use change. Effective October 1, 1889. Directions to Property: This is to certify that the information provided Is correct to the best of incurred from thisapplicatio ATE/ and I understand I am responsible for all charges SIGNATURE CONSENT FOr3 SITE EVALUATION IQ. BE DQNE QN ABOVE QEEIR BED PR�PERT MUST CHECK ONE: ❑ 1. 1 OWN the property. - ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (12-90) %CGS ^1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT A)e e Q Davie County Health Department Environmental Health SectionP. V OMocksviIIe, NO 27028 J� 1. Application/Permit Requested By Aa % 1flA�- Mailing Address •ok'bV,,2 6 i — Home Phone Z`ZX 2. Name on Permit if Different than Above — 3. Application/Permit for: 4. System to Serve: ouse Business Phone ❑ General Evaluation ❑ Mobile Home lzr—s—ep�tic Tank Installation ❑ Place of Public Assembly. ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision / f��'r������� Section Lot # No, of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions 6. If business, Industry, place of public assembly, other: Specify type No. of People Served No, of Commodes No. of Lavatories _ No. of Showers No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: ❑'Public ❑ Private 8. Property Dimensions ISb Z;200 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? ❑ Yes If yes, what type? ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal ❑ No ❑ Community [_:OTE. Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the Intended use change. Effective October 1, 1989. Directions to Property: This is to certify that the information provided is correct to the best of Incurred from this applicatio . � DATE and I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE )=VALUATION 1Q BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 QM the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 1 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE DCHD (1280) SIGNATURE DAVIE COUNTY HEALTH DEPARTMENT -S'OG'3 Environmental Health Section Soil/Site Evaluation f✓©'broo�t' NAME i7ADATE EVALUATED ADDRESS PROPERTY SIZE �Od PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well Community Public Y/ Evaluation By: - Auger Boring Pit L/ Cut' FACTORS 1 2 3 4 Landscape position G Slope % — HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ' Texture groupG G' Consistence Structure ib/l 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 ;t SITE CLASSIFICATION: EVALUATED BY:['� LANG -TERM ACCEPTANCE RATE: i 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-LoamSI-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 , DCHD (01-901 lob' -711 lo -19 eC rQ. DAVIE COUNTY HEALTH DEPARTMENT NO�I Environmental Health Section Soil/Site Evaluation NAME' frJn A5 DATE EVALUATED ADDRESS PROPERTY SIZE /DD "�00 PROPOSED FACIILTY /7/gUf/ LOCATION OF SITE Water Supply: - Evaluation By: On -Site Well Auger Boring Community Pit - Public Z ­f Cut - Slope % - HORIZON I•DEPTH FACTORS 1 2 3 4 Landscape position 4.� Slope % - HORIZON I•DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH r -4/ Texture group Consistence i Structure / -b A' 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 q SITE CLASSIFICATION: P.1 EVALUATED BY: Aq,/ 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, 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-Fiirri VFI-Very firm EFI-Extremely firm Wet _ NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP -Nonplastic 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 DCHD(01-901 .T Davie County Nealtlr Deppartment. and .7�orne ,7�ealtFryency 210 HOSPITAL STREET I P.O. 13O% 665 MOCKSVILLE. N.C. 27028 PHON E:(704) 634.5985 April 21, 1992 .Mr. Rudi Faak Rt. 8, Box 267 Mocksville, N.C. 27028 Re:.Site Evaluations Lots 15, 16, 17 Stonybrook Dear Mr. Faak: As requested, a representative from this office visited the aforementioned sites on April 3.6, 1992. The three sites (lots 15, 16, 17) were found to be provisionally suitable for the installation of ground absorption sewage systems. - - If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R..S. Environmental Health Section Enclosure U� 1. Application/Permit Rec Mailing Address Home Phone - APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PERMIT Davie County Health Department �J Environmental Health Section P. O. Box 665 n /� Mocksville, NC 27028o/� By 2. Name on Permit if Different than Above _ 3. Application/Permit for: 4. System to Serve: ouse Business Phone ❑ General Evaluation I Septic Tank Installation ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry L ❑ Other ❑ Unknown YA 5. If house, mobile home: Subdivision �f0/�/�/ FJl��� Section � Lot # -®' No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes _ No. of Lavatories _ No. of Showers No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: M-15ublic ❑ Private 8. Property Dimensions IS49 L12M Sewage Disposal Contractor ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? ❑ Community NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: 0,);" , � ,// id. This is to certify that the information provided Is correct to the best incurred from this applicatio . 2/a �3A DATE and I understand I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE DCHD (1290) .�.: /7 Secy , • � : ,: DAME COUNTY HEALTH ,DEPARTMENT ,Zoe` Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE T ' Ya "A b PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well Commuaity Public .Evaluation By: Auger Boring - Pit -,— Cut FACTORS 1 2 3 4 Landscape position b L Slope % - - HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH til( 9g 8f Texture groupC Consistence Structure 5 rb/C 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: U S LONG-TERM.ACCEPTANCE RATE: REMARKS: DCHD(Q1-901 Landscane Position EVALUATED BY: Ao l/ i OTHER(S) PRESENT: LEGEND 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 Moist VFR-Very friable FR -Friable FI -Finn VFI-Very firm EFI-Extremely firm Wet NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP -Nonplastic 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 watef 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 Dan? County A(ealtli rDepartment and .poke Jfealtlf gyency 210 HOSPITAL STREET I P.O. BOX 885 MOCKSVRLE. N.C. 27028 PHONE: (704)834.5985 April 21, 1992 Mr. Rudi Faak Rt. 8, Box 2.67 Mocksvi.11e, N,C: 27028 Re: Site Evaluations Lots 15, 16', 17 Stonybrook Dear Mr, Faak: As requested, a representative from this office visited the aforementioned sites on April 16, 1992, The three sites (lots 15, 16, 17) were found to be provisionally suitable for the installation of ground absorption sewage systems. If you have any questions, please feel free to contact this office. Sincerely, ✓. Robert B. Hall, Jr., R.S. Environmental Health Section Enclosure