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392 Michael's Road Lot 15L �AUT,JIORIZATION NO: VA -0 � � � j DAVIE COUNTY HEALTH DEPARTMENT ' ��'' ' Environmental Health Section PROPERTY INFORMATION I'L tee" P.O. Box 848 ��-- Name: Mocksville, NC 27028 Subdivision Name:�+7�1��� Phone #:704-634-8760 Directions to property: 1Z Section: F Lot: _S AUTHORIZATION FOR �¢ WASTEWATER Tax Office PIN:#�—/--� - SYSTEM CONSTRUCTION Road Name:Zip: _ !J **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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ti, IS VALID FOR A PERIOD OF FIVE YEARS. /,r ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ,,,DAVIE COUNTY HEALTH DEPARTMENT - IMPROVEMENT AND OPERATION PERMITS. PROPERTY RMATION Pe }s ,- Nane '- - 1' Subdivision Name.dim ir&tions to property: Section: .. IlNPROVEMEIVT J.. - •PERMIT Tax Office PIN:#Ado } Road Name: ' Zip: A7. . **NOTE** This Improvement Permit DOES NOT authorize the constriction of 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 constmctionhnstallation 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 PERNUT 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 SYSTENL _ RESIDENTIAL SPECIFICATION: BUILDING TYPE 0 /� # BEDROOMS - #BATHS _ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE: Yes or No LOT.SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) � NEW STfE REPAIR SITE ?. . SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH I ROCK DEPTH LINEAR FT. ,Th OTHER REQUIRED. SITE MODIFICATIONS/CONDITIONS; . - APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed R("I--r P (Yrn 0 n Contact Person )/^ Mailing Address P C) Home Phone City/State/Zip O jock °( ria °c_, _fx �(��� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address _ 3. Application For: 4. System to Serve: 5. If Residence: ❑ Dishwasher 6. If Business/Other: # Commodes _ If Foodservice: City/ tate/Zip ❑ Site Evaluation ���� Improvement Permit & ATC El House �Mllifet�'Mf e XtC ❑ Business ❑ Industry ❑ Other ❑ Both # People # Bedrooms 3 # Bathrooms ❑ Garbage Disposal U.d Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing Specify type k) /A # People # Sinks 7. Type of water supply: # Showers # Seats 8 County/City # Urinals Estimated Water Usage (gallons per day) ❑ Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes �No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: ) a 69 , 1� a4 Is Tax Office PIN: # I - - Property Address: Road Name \39a city/zip MX-kS (J T-LL6. , PJ G i;�> 116 32 If in Subdivision provide information, as follows: Name: Section: Lot #: /.117 WRITE DIRECTIONS (from Mocksville) TO PROPERTY: ':� 4n/y4te-5 i ,v,d m nen-JA lame-, CG :-f -rte.. rn k vard 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 by as necessary to determine the site suitability. DATE cq SIGNA Revised DCHD (06-96) V conduct all testing procedures APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM I y Davie County Health DepartmentF Environmental Health Section JUL 2 1 1995- bL`f P. O. Box 665 Mocksville, NC 27028 EALjH Do I P I � 1. Application/Permit Requested By f ok7'a &ryn e- C. r T/ Mailing Addressf .r �..{�;'" Home Phone _ JYl 0 /��5 , �; �J Business Phone k 7 s2 `�✓C� 2. Name on Permit if Different than Above 3. Application for: / General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: ®'House ❑ Mobile Home ❑ Place of Public Assembly] ❑ Business ElIndustry /1. ❑ Other ❑ Unknown JJ 5. If house, mobile home: Subdivision T� Section l Lot # 1_ ❑ Basement/Plumbing No. of People I Basement/No Plumbing No. of Bedrooms No. of Bathrooms -' Dwelling Dimensions ' loo 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: ublic ❑ Private 8. Property Dimensions d O r71-- �� ,:0Q©r Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ 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: o/ SO.A 9-7-V l A �� t5 --h—. /G7� V ` �lY L9�5 PJ'W This is to certify that the information provided is correct to the best of my knowledge, incurred from this a plication. �Z - Ze'? DATE I understand I am responsible for all charges SIGNATURE ;k 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 De�wwe Co my Health Q,�eeppartment to enter upon above described property located in Davie County and owned by ;� s o l�od , ed'u; ce11Lc to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. C 2�Z 7m. -- �, J DATE DCHD (1193) t- ; �.5 DAVIE COUNTY HEALTH DEPARTMENT ��• Environmental Health Section Soil/Site Evaluation J ,/ NAME Zr. 2 DATE EVALUATED ADDRESS PROPERTY SIZE 'lao r_ee-o PROPOSED FACIILTY 1;!�244e_l LOCATION OF SITE Water Supply: On -Site Well Evaluation By: Auger Boring Community Pit i l FACTORS 1 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group' Consistence , Structure 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: / l_� EVALUATED BY: euk&' LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND DCHD (01-901 Public Cut 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- 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 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