The URL can be used to link to this page

256 Dublin Road Lot 16+ZATION NO 11.7.61 DAVIE COUNTY HEALTH DEPARTMENT Environental Health Section PRO mPERTY INFORMATION ,./ Permnf4ers Y P.O. Boz 848 �g Name. CY,' ' ':Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 / Directions to property: r �/a / Section: Lot: /b / - -AUTHORIZATION FOR /r-%'rte/✓'WASTEWATER Tax Office PIN: SYSTEM CONSTRUCTION' 40/ Road Name: **NOTE** This Authorisation for Wastewater System Construction MUST BE ISSUED by the Davie County EnvironmentalHealth:Insp6ctions]: �.' to issuance of any Building Permits. This' Form/Authorization Number should be presented to the Davie County Building Office when applying for Building Permits. CIn'compliance witli Article I1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) **NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS ENVIRONMENTALHEALT SPECIALIST,, DATE ISSUED Wr ., r -�-. .-....r.rr uf-'r• w. ,.. _-."ia•.+' '.' 'rr� Yew Y:^Vf%V- b��.y.:µ...�'r..iot7"4'b�.i � pi..y ..: rv.�.. -y.- _. -.. _. 1 1 6 DAVIE COUNTY HEALTH DEPARTMENT 3 N IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permuf?e s;- e•Nam/Z Subdivision Names✓ Br� / " Directions 46 to property: ani vy� : ,�/ y' %!; Section: % `Lot:. IMPROVEMENT i, .;^ . % , /ia. <`!✓ PERMIT Tax Office PIN:1 � - ZE--, °- Road Name:t� 11 nP: l/> "o **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. i AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained ftom this Department prior to the constmctionlmstallation of a system or the issuance of a building pemvL < (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***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 A.4 # BEDROOMS - # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPES # PEOPLE # PEOPLE/SHIFT T # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE/ -SD TYPE WATER SUPPLY e DESIGN WASTEWATER FLOW (GPD) NEW SITE—J!NDREPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH L LINEAR Fr. 3D6 OTHER REQUIRED SITE "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) 634-8760. OPERATION PERMIT' \ SYSTEM INSTALLED BY: �/a�ff/S •Cid„ - �t AUTHORIZATION NO. ��— OPERATION PERMIT B �.oDATE: `� a a, V **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAA& SYSTEM DESCRIBED ABO 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 TATE. DCHD 05/96 (Revised) P- -r y. - -.-,- -wry �•^- '�ro•we.,� rwe Y.. /r.vv ,,. ., t (.��':':xt- rr-'.c . . �- K�\^ 11 % 6 DAVIE COUNTY HEALTH DEPARTMENT 3' { d< "-* IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATIONIt tryN�c�� Namee.ir + Subdivision Names /� e r " Directions to property: > r' - /r Section: Lot: . IMPROVEMENT 'F ,�'. , /. •:.- �`: �' PERMIT. - Tax Office PIN: 7457ZA Road Name:--�'-FLSp: e,t r: r% **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater System::Aii 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SE,. 'i✓�� -' - '� r _ `• ` !"' PLANS OR THE INTENDED USE CHANGE. YOUR WASTf,WATERIT ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED - SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. r• RESIDENTIAL SPECIFICATION: BUILDING TYPE, 9 # BEDROOM$ # BATHS # OCCUPANTS GARBAGE DISPOSAL. Yes or No e COMMERCIAL SPECIFICATION: FACILITY TYPER PEOPLE _ # PEOPLEIS'HTFT _ #SEATS INDUSTRIAL WASTE: Yes or No LOTSIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)"n, NEW SITE •y REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL.' PiJMP TANK ' GXL ,„TRENCH WIDTH > G ROCK DEPTH L LINEAR PT r OTHER , / 5 "REQUIRED SITE MODIFICATIONS/CONDITIONS. IMPROVEMENT **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,Q7(l4) 6348760. j' OPERATION PERMIT \ YSTEM INSTALLED BY:e" J dc:N 2 C AUTHORIZATION NO, i OPERATION PERMIT B DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA TSYSTEM DESCRIBED ABO* 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 05/96 (Revised) - d APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department D Q V Environmental Health Section V P.O. Box 848 JAN 2 11998 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. J /, 1. Name to be Billed / I/ /o ►r Ywi t -i Contact Person 1<< Tel ✓K Mailing Address f'Q WeifEmd13ILid HomePhoe j?3I—gf"�7!o City/State/Zip by — S -7--710 1 Business Pho.WD % 2 "z — l is o! ( i 2. Name on Permit/ATC if Different than Above Mailing Address Set '""L City/State/Zip 3. Application For: [ ] Site Evaluation )('Improvement Permit & ATC t1t 4. System to Serve: MHouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People_ # Bedrooms 3 # Bathrooms -2, Dishwasher [ ] Garbage Disposal 7 c Washing Machine [ ] Basement/Plumbing PC_ 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:,[dCounty/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes D -Mo i If yes, what type? t EITHER A PLAT OR SITE PIAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ** VM' OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: .0 Y.10 7LA70 WRITE DIRECTIONS (from Mocksville) TO PROPERTY - Tax Office PIN: # 5781 - 73,5 -75S Property Address: Road14ame V tlI� Q�� [� (P L k tqL City/Zip P6 fAl4L2 L DU I" If in Subdivision provide information, s follows: Name: �/1( ✓o L �GC ✓� S Section: Lot#: 1' i.o 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 submittedin 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 JL:/rL'//r�lli"L'LL:1 L, Revised DCHD (06-96) THIS AREA WAY BE USED FOR DRAWING YOUR SITE PLAN: Zoe above described property located in Davie County and owned procedures as necessary to determine the site suitability. /Sb DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME / DATE EVALUATED ADDRESS ��`�'-ncc � a% PROPERTY SIZEe9 PROPOSED FACIH.TY LOCATION OF SITE Water Supply: On -Site Well Community Public Lir Evaluation By: Auger Boring Pit 1/ Cut FACTORS 1 2 3 4 Landscape position 77 Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogyr HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION Ft LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: <0S EVALUATED BY: LANG -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 ,lay 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 -Firm VFI-Very fine 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 3C --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