430 Michaels Road Lot 194 - d4.YT� _`--.. .1 f,( _s.kxt .R` _ ( j1Yi" '.�r�4n i?♦. -y 2-. Y\ .\. .�".. .. . .d !'- t D: . .. r t `L ..,',.'_� .. � a.
fHORIZATION NO: 1565 DAVIE 9OUNTY HEALTH DEPARTMENT
PROPERTY INFORMATION
Olt
Environmental Health Section
Permittee's ' P.O. Box 848
Name '� Mocksville, NC 27028 Subdivision Name:.�<=S
r Phone # 336-751-8760
Directions to property:"►* Section: Lot:
"71/ AUTHORIZATION FOR F
/ e%��s WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name:
**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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST
DATE ISSUED
� ^C T7�1' R'ti^-.j�v.^�^' . "�#y1T^�:r�,� ?� ..-.� ��' »,� t". •_'�,.J,.,�r..,,. ,�.r ,+...Jc_.,,+_...::;7,.,.;. j.::.. `
7 W,r7 `► DAME~ AT HEALTH DEPARTMENT
h j4
TMPRO EMENT AND -OPERATION PERMITS PROPERTY INFORMATION.
Subdivision Name: • I ". a
,. Du+ections to. property: •' ` ' ` Section: 1 Lot:ii
PD
_Il"ROVEMENT ,r
PERMIT Tax Office PIN:#�.
Rad Name ` w �cd�I.
**DOTE*.*-This'Improvement Permit DOES NOT authorize the construction or ixlsta] on of'a septic'tank system or any wastewater System. An,
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained frim this Department prior to the
construction/ulstailation of a system. or the: issuance of a Building permit
(Incompliance with Article Il of•G.S,.Chapter 130A, Wastewater'Systems, Section .1900 Sewage Treatment and DisposdSystems)
*s*NOTICE*** TMS PERMIT IS SUBJECT TO REVOCATION IF SITE .•'
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
'ENVIRONMENTAI,.HEALTH SPECIALIST ,` DATE'ISSUED SYSTEM CONTRACTOR MUST SEE THUS PERMIT BEFORE
'INSTALLING THE SYSTEM. ,
RESIDENTIAL SPECIFICATION: BUILDING TYPE / # BEDROOM S.s I BATHS .Z # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION:.FACILITY TYPE # PEOPLE - k PEOPLEISHIFf • # SEATS INDUSTRIAL WASTE: Yes or No
LA)TSMIAMI, TYPE WATER'SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE_ REPAIR SITE
SYSTEM SPECIFICATIONS.: TANK SIZF GAL. PUMP TANK ' GAL:. TRENCH WIDTH �� y - ROCK DEPTH LINEAR kl--z/
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
t4CONTACT 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 (336)751-8760.
OPERATION'PERMI T
SYSTEM INSTALLED BY:
1 0
AUTHORIZATION NO. ' 'N"� OPERATION PERMTT'BY. DATE:
-J, L
THE ISSUANCE OF THIS OPERATION PERMIT SHALL.INDICATE THAT THE STEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A,'SECTION .!900"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.
u�..u, uwyo �rcevuea� -
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &
4 Davie County Health Department
Environmental Health Section U
P. O. Box 848 Jvy `
Mocksville, NC 27028
(704) 634-8760 _ .,��ctaSALH�ISH
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLUS --"'-
kpxrALLTHE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed JP d ma'~ Contact Person poaer
Mailing Address 0 P t✓" 739 Home Phone J-9-274-7
City/State/Zip 610 P Qg� �]� a-10/ � Business Phone q�,V `` 2,551
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve
5. IfResidence:
C� Dishwasher
City/State/Zip
❑ Site Evaluation 9 Improvement Permit & ATC ❑ Both
❑ House O/Mobile Home ❑ Business ❑ Industry ❑ Other
# People # Bedrooms '3 # Bathrooms
❑ Garbage Disposal 9' Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type
# Commodes
If Foodservice:
7. Type of water supply:
# Showers
# Seats
County/City
# People # Sinks
# 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 ENo
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: /0& X 3o f
I
Tax Office PIN: # -7 45 - 1 - 7 I
Property Address: Road Name INV� -('�r9 6�0 a I
% U 02% '
City/zip 0M- i
If in Subdivision provide information, as follows:
Name: & aatt"" A m�s
Section:
Lot #:
19
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Cz� S 4D
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
rk,
as necessary to determine the site suitability.
DATE % —ILI- / SIGNATURE
Revised DCHD (06-96)
testing procedures
t ,
a, �- a? �,
axA l ///
�•' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM
I
Davie County Health Department
Envi tal He Ith Section . f JUL 2 11995-
P.
1995
P. O. Box 665
Mocksville, NC 27028 EALTH
1. Application/Permit Requested By r o''1 O '_aV n %_erJ e-- ZJC • 6)C1 rt ki ce-
�+ t �. l41-11-'� Home Phone 6 3 3g 33
Mailing Address .. l_ _ .i' r ._:
Business Phone 0.?? 7 s2 `✓ �3
2. Name on Permit if Different than Above
3. Application for: General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: ®'House p Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry nn. ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision -� 'T i1' G�Q� Section Lot #
i
No. of People
No. of Bedrooms
No. of Bathrooms -:44
Jill 91
Dwelling Dimensions --j �100
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
fgOO s �� ❑Dishwasher
❑ .Garbage Disposal
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 �Q� F Sewage Disposal Contractoi
1-11
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes "0
❑ 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:ll6DD !—
a
/
® S 97V�
F � '
This is to certify that the information provided is correct to the best of my knowledge{
incurrFm
this application. �
m* j (y %Q
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 my Health DLepartment to enter upon above described
property located in Davie County and owned by tnnd t v az > (yo;ip, Ghc -
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system. q C
1/7 -- / J
DATE
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
j Environmental Health Section iR
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY�r441rP-
�y i
DATE EVALUATED 94 "1
PROPERTY SIZE 1A141CZ1,1D
LOCATION OF SITE , 6
Water Supply:
On -Site Well
_ Community
Public /
Evaluation By:
Auger Boring
Pit
Cut
FACTORS 1 2 3 4
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupC G
Consistence T
Structure S'
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: EVALUATED BY: A Z/
LANG -TERM ACCEPTANCE RATE: 'e 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
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
DCHD(01-901