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324 Michaels Road Lot 6AUTHORIZATION NO: � � � � DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section PROPERTY INFORMATION Perniittee's�- P.O. Box 848 Name: {� t l " tt - ClLLly A,) Mocksville, NC 27028 Subdivision Name. , AL.l i c Phone #: 704-634-8760 G, Directions to property: 0 n 1 t e� Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#'S 71/62 /o - SYSTEM CONSTRUCTION Road Name: P 1; ,! 1 •� t= t S O -Zip: ,i=Za **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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION I IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL'IMALTH SPECIALIST_) DATEBSUED �.....rk, y E'E' .- - �. .0 �), �Li tiy�,,:p.;:.�{y'�{ •M ` .yid Vl' DAME COUNTY HEALTH DEPARTMENT IMPROVEMENT. AND OPERATION PERMITS PROPERTY INFORMATION "'� �'":- •.tNI; Subdivision Name:ib.l t. D1reCtrOrIS t0I)IOpely'. r t Section: I4PROVEMU4T -- IA's F , t !#" PERMIT Tax' Office PIN:# Road Name:i llZlp: **NOTE** Ibis Imprdvement 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 Depaitment prior.6,the constcuctiorihw iahnon of a system or the issuance of.a building permit. (In compliance:with Article 11 of G.S.,Cliapter 130A, Wastewater Systems,.Section 1900 Sewage Tmatmerit and Disposal Systems) THIS PERMIT 1S SUBJECT TO REVOCATION IF SITE PUNS`OR•THE INTENDED USE:CHANGE. YOUR WASTEWATER �—�' �— SYSTEM CONTRACTOR.MUST SEE THIS PERMIT. BEFORE' ENVIRONMENT TH''SP ST ' DATE SSUED INSTALLING THE SYSTENL RESIDENTIAL SPECIFICATION: BUILDING TYPE M1 -I ' #. BEDROOMS — #.BATHS #'OCCUPANTS GARBAGE DISPOSAL: Yea or No COMMERCIAL SPECIFICATION: FACHM TYPE, # PEOPLE It.PEOPLE/SHIFI - #SEATS : INDUSTRIAL WASTE: Yes or No LOTk! SIZETYPE WATER SUPPLY' �� DESIGN WASTEWATER FLOW (GPD) - NEW SITERFPAIIt SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH (Z LINEAR Fr. -OTHER i LH1SI�IIC1�• r REQUIRED SITE MODIRCATIONS/CONDMONS: IMPROVEMENT PERMIT LAYOUT 16; *.•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. ; ' . { I DAVIE COUNTY HEALTH DEPARTMENT r''•,. <;,t IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION 'Permittee 'a,s Name.` Subdivision Name: '' Directions toY P ro ert f Section: Lot: P IMPROVEMENT " PERMIT Tax Office PIN:# Road Name:`' + Zip: t **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 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) ENVIRONMENTAL HEALTH SPECIALIST 1 ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING;TYPE # BEDROOMS ^ # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZEiX TYPE WATER SUPPLY (-I-^ DESIGN WASTEWATER FLOW (GPD) �j=""r� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH .?� , t ROCK DEPTH 1 2 I 1 LINEAR FF.,C C' , OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT j Ti J C **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: AUTHORIZATION NO. 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 05/96 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT `t4 tv7 rg 9 C1, Davie County Health Department Environmental Health Section P. O. Box 848 OCT 2 9 1997 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 'Q�: , 1 h'1 a' Contact Person ry Mailing Address J' ,� -736 Home Phon �� a g��/�o`-�`�� City/State/Zip 0001 rn i /C a-10 1 Business Phonel-7U� �87 '`5l 2. Name on Permit/ATC if Different than Above Mailing Address _ 3. Application For: 4. System to Serve: 5. If Residence: GYlsishwasher 6. If Business/Other: # Commodes _ If Foodservice: ❑ Site Evaluattiion�� Ll House GYMobile Home # People City/State/Zip J' Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms ❑ Both ❑ Other # Bathrooms ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing Specify type # Showers # Seats # People # Sinks # Urinals Estimated Water Usage (gallons per day) # Water Coolers 7. Type of water supply: 0--county/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes UINO- If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: _100' )(303' I Tax Office PIN: # l - to - I I Property Address: Road Name ,a� City/Zip ()�-o &k.6y iUt u Yl C a7 oz8 If in Subdivision provide information, as follows: Name: Section: I Lot #: WRITE DIRECTIONS (from Mocksville) TO PROPERTY: b -e 0-�L 1 flog- s idv 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 D.avvi^e, County Health Department to enter upon above described property located in Davie County and owned by D �` L 1 I ( CLw it to c /duct all testing procedures as necessary to determine the site suitability. t DATE 10 a SIGNATURE Revised DCHD (06-96) /f f t/ -v t1l APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI D Davie County Health Department E • t I H Ith Setion c % nvironmen a ea- 2 19 95- / t j P. O. Box 665 I Mocksville, NC 27028 1. Application/Permit Requested By I o%7 'a 'aIrn SerJit— IrPC - + L Mailing Address r_ i+ EHome Phone (o 144 �/ 3gc3' 13 T6��`y /S d� //�� BusinessPhone 2. Name on Permit if Different than Above 3. Application for: A4 General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly( ❑ Business ❑ Industry ❑ Other ❑ Unknown J /n► -ciS 5. If house, mobile home: Subdivision 'T "`L GyQ� Section _ Z Lot # _,jc i No. of People No. of Bedrooms No. of Bathrooms „��• f DD l 04 Dwelling Dimensions , �lig 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ublic ❑ Private 8. Property Dimensions ,�C' O Fly Z ,To© 1'r7* Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ .Garbage Disposal ❑ Yes "o ❑ 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: Ir �DO B S� rr7 s G --fl S This is to certify that the information provided is correct to the best of my knowledgeti, incurred (from thi a plication. �, n DATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED F?ROPERTY 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 representativ of the Davie Co,u my HealthD�epartment to enter upon above described property located in Davie County and owned by is x Fodni `j e✓v;'ce l�>>r to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE DCHD (1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation DATE EVALUATED 156,1,7 Z6!5__ PROPERTY SIZE Dd LOCATION OF SITE Z?- d 1 NAME ADDRESS PROPOSED FACIILTY �� 9 Water Supply: On -Site Well Evaluation By: Auger Boring Community Pit c� Public t/ Cut FACTORS 1 1 2 3 4 Landscape position 41 Sloe Z HORIZON I DEPTH Texture group Consistence Structure MineralogZ HORIZON II DEPTH r Texture groupL Consistence r Structure / MineralogX-i HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure MineralogX SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: _ EVALUATED BY: 1� LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R -Ridge S -Shoulder L -Linear slope FS-Footslope 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- V+ ---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 ,;C --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 Control Comer 31.74' 70.41' �i V) O o GD r; e z r a lines. 9uildnc Line 31 73' 100.00' 100.00' 100.00' 100.00' ,9 08 � o ticn -' .1 q a) M LO M C� c q h M t- ° CIj O "' ° 1� O M q r r7 r z r z z z 77-7-T 100.00' 90.57' t 135.00' 106.00' f cc �� o o LI) ib 0 M c r 0 C 6 ' f•� O ° O O r .'M ° O O ca co r i`.^ r .� Tax Lot 41 z z z z z '3; a Tax Map L-5 Chares Eubie Evans, Jr. ` ab? Carol Jean Alexander r x DE 85 © PG 349 _ 1 f _ 1 J 100.00' 6C.15' 106.23' 106.00' Control Coma. 68.27' - � a..; .. n - - r 1, ; + _ 19- =ioN 12°00'00"E • 147.96' ,:._ .y.-.. N 10044,15"E N I G"62'2u"c MOv.4:+ - Public 60' R\W (20' grovel) 11.32 N 10-52'10"E 400.00 N 10047'05"E N 12000'00"E N 12000'00"E N 13"16'05"E N _ 13`2E i Qo -.. r_ - 1 R 101.0) cv2.08' C00D' 00,00' 1F,0' 32.36' 1030 ' C- 10 27.8E5 4Sv�.4-4�#_ 0 0 t L7 O O N O N r f -'q O O O O j� r^��;'' p O I Mr7 oCe N d O N O O c p O p l ;3 Tax Lot 40 P) oO � D r CO O N r z z�"' '`' • Tax Map L-5 U6­ 2� 278 29 30 31 32 3334SadieNexonder }(2-J5 ( o o U Elsie Pexondcr Y - D3 76 Q PG 3981 z 100.00' 100.00' 100.00' J� 101.53' 99.46' 122.39' 102.35' 100.09 125.3�s' Vii. 124.96' N 1 1001'05"E 200.09' N 11001'05"E 400.99' N 14° 14'50"E 475.09' CD M _ eWeUl ' "�"4J