156 Equestrian Lane Lot 3' qtr-t r •'` y i :f,.. 'P ; k..,. � ; h ::�` i.' - r f_4. •Y ,.. '+.,. - _ y,.,. x:
AUTHORIZATION NO: `P DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee'st. P.O. Box 848
Name: �e711 -" 3 Mocksville, NC 27028 Subdivision Name: 0" fa I t, --
Phone # 336-751-8760
Directions to property: Vit' tJ 'I T- A 0 Section: Lot: �✓
��. AUTHORIZATION FOR
WASTEWATER Tax Office Office PIN:#/—,77yi2 ,
SYSTEM CONSTRUCTION -.�'--
Jj�.) ��'�n)lLL ! t�►'.rJ �% t-J +— ^U4�ji'ii�A� C� L e i p R JJ j�
Road Name .. Tr l9 1 }Lip: +%t^o`
**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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
14 ` Ib IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONKi TAL HEALTH SPECIALIST? DATE SSUED
y '9�•s. '.►tl .Fi. 1 .��'^'� li''L ��.�"�'�'� 4 � < -f i'i-t—�'.�..--•9). S- L• ,....». Je ,c , , � A
DAME` OUNTY HEALTH'DEPARTMENT
T1vjPR0j MENT AND:OPERATION PERMITS PROPERTY•1NFORMATION
Tc
r 4l N Viz;,. L�4 • �` is ' Subdivision Name:
Directions to property -' ''::'►+ `� Section. Lot:'
IMP
EpERNIIT Tax Office PIN:# -
ip• "
# Road Name: � Q
.. _
1, '
**N t **This Improvement Permit DOES NOT authorize the conswctlon or installation of a se phc tank system or any wastewater system An
AUTHORIZATION -FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this. Department prior to the { �_
z eonstructidnrinstallation.of a system orthe issuance of a building�ermit ,
(E► co h with Article 11 of G.S.'Chapter 130A{ Wastewater Systems, Section .1900 Sewage Treahnent and Disposal Systems)
I it
***N(MCE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDID USE CHANGE. YO ASTEWATER
O fiH�SP DA ISSUED SYSTEM CONTRACTOR'MUSTSEE THIS _ BEFORE a
f INSTALLING THE:SYSTEM: '
RESIDENTIAL SPECIFICATION.' BUILDING TYPE BEDROOMS W # BATHS . ! #, OCCUPANTS _ "5 GARBAGE, DISPOSAL: e gr No
COMMERCIAL SPECIFICATION: FACILTTY.TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No-
LOT SIZE O """"" :TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) . NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 1 GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR Ff. _i2i '
OTHER �l�t-t� NA) 2 � T? 1�-TQIbo
��+� arta=
REQUIRED SITE MODIFICATIONS/CONDITIONS. ' �NSTq ON CA7tI*f�� j'}ICi�C'; +51 1. /oJS
*'CONTACT A•REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:36;04. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.•
DCFID 05* (R-ip 0
APPLICATION FOR SITE EVALUATI
/ Davie County Hea#
Environment4l He,
I / P. O
n �� r �; � q�4�✓i C
1. Application/Permit Regt
Mailing Address I� (:2 C- �J • - j' r J • �— Home Phone -7 cl' Z o 2
✓�%, .- ��, P, n1 _ L . -2-i �_ Business Pho a
.� / % d -
2. Name on Permit if Different than Above
3. Application for:
D,55-`n-eral Evaluation a Septic Tank Installation Permit
4. System to Serve: 014use ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision w� = - w . / Section Lot #
n- asement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 'ErVashing Machine
1
No. of Bathrooms .•z„ 3 �shwasher
Dwelling Dimensions �''� arbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: C9'Public ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor I %r%: % t
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes N -No
If yes, what type?
"NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: PROPERTY INFORMATION REQUIRED:
f1 Tax Office PIN: # _S -f;!3 2-070'o?-
a-w:qOPERTY ADDRESS, as follows:
Road Name: 147e,
�� City: -F-,fl'15, /`/. .
�
�-
II SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
y /a 6
V- X076
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ice' I 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 representativ .of the Dayyie County Health Department to enter upon above described
property located in Davie County and owned by %6- - t f3-® 9-V
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE 4IGNATURE
DCHD (193) ��- L /- O
�y�
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
/ Soil/Site Evaluation
NAME �DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY A"e LOCATION OF SITE
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2
3 4
Landscape position .0
L
Sloe R
.41
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure it
Mineralogy
HORIZON III DEPTH rZ
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: v mo i( zo �7C' EVALUATED BY: /bit. �Z
LONG-TERM ACCEPTANCE RATE: '
REMARKS: 4/igl l�
LEGEND
ER(S) PRESENT:
l .v1,.
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
CONSISTENCE
Moist
VFR- Vf:.-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
3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mi neralosry
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
w Dame County Nealtl Department
and .Mame Xealtk ffyency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634-5985
April 17, 1996
Mr. Con Shelton
186 Cedar Ridge Rd.
Mocksville, N.C-. 27028
Re: Site Evaluation
Whip -O -Will Lot 3
Dear Mr. Shelton:
As requested, a representative from this office visited the aforementioned
site on April 10, 1996. Based upon the information provided on the application
for a site evaluation and after an evaluation was completed, the site was found
to be provisionally suitable for the installation of an oversized -modified on
site sewage disposal system.
If you have any questions, please feel free to contact this office.
Enclosure(s)
y
Sincerely,
Aec-ve &' i��A .
Robert B. Hall, Jr., R.S.
Environmental Health Section