Loading...
232 Longwood Drive Lot 31Perthittee's DAVIE COUNTY HEALTH DEPARTMENT 1 45 Ot6 6' PILI' Name: - t/l l!5 -e J!Crd Environmental Health Section PROPERTY I F ATI �i1�, ,/► . [J L16 P.O. Box 848 �C o� Directions to property: V Mocksville, NC 27028 Subdivision Name: Q w-• (n� Phone #: 336-751-8760 ( 3 1 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#56&f - 5_ - 7?7� SYSTEM CONSTRUCTION 3� /]� AUTHORIZATION NO: 003030 A Road Name: LO �� "Lip: 97Upei **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) �., I ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION (j IS VALID FOR A PERIOD OF FIVE YEARS. AL HE LTH SPECIALIST DATE ISSUED permlhge's; DAVIE COUNTY HEALTH DEPARTMENT 1 n k lame. ' ""{il t �j `Pr/J Environmental Health Section PROPERTY INl~(3RI�ATION, ;! ToP.O. Box 8480< Directions to property: r--- Mocksville, NC 27028 Subdivision Name: L! �.-�' (�, ' �S L)�l Phone #: 336-751-8760 ( ` Section: Lot: L>P AUTHORIZATION FOR {WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION l AUTHORIZATION NO: 0 0 3 0 3 0 A Road Na3 e� � �N � k1 ac� �p: 2 %G06 **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 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) f� *NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION i IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE � # BEDROOMS __�_ # BATHS # OCCUPANTS __4 GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Ye L 6f 90 LOT SIZE 0 TYPE WATER SUPPLY �%C lie DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE 0OGAL. PUMP TANK IrOC: AL. TRENCH WIDTH 36 Y q3(e� SYSTEM SPECIFICATIONS: TANK SIZE � F ROCK DEPTH LINEAR FT. OTHER As stated in 155AGAG r P_ v " e"101 accepted Systems may also be use REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT,, A L..O wt5't- ��� t /►1 S 17 'e 7 /K ►7 'v-eo vt �o �c a Y \ t ✓I— y 1 'r G d - cy I 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT —�� —4— !/ SYSTEM INSTALLED BY: g 100 ` /. J "//UC 7,)' 71 e �' u�r�► l.. �G�. n � s ^�--� !oa . s atiu / Q f. � � C Xa AUTHORIZATION NO. 03 O1,0 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 02/02 (Revised) �A Perinittee's DAVIE COUNTY HEALTH DEPARTMENT i Mame'' �" )11 t �� `� `f (iI 1 Environmental Health Section PROPERTY INFORMATION µ r f t �%P.O. Box 848 1 <•t Directions to property: (,y_. / `' Mocksville, NC 27028 Subdivision Name: i .- Phone #: 336-751-8760 1 •� p;C. C 6:. � "� --' Section: Lot: -� AUTHORIZATION FOR WASTEWATER Tax Office PIN:# �& SYSTEM CONSTRUCTION 003030 � e 1 GY � Lti c,r_.r1 (4i AUTHORIZATION NO: A Road Name: 1p: **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 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED f RESIDENTIAL SPECIFICATION: BUILDING TYPE' #BEDROOMS L! #BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No t1 LOT SIZE r U TYPE WATER SUPPLY (0 Q/ DES�GN WASTEWATER FLOW (GPD) � NEW SITE R PAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 0 GAL. PUMP TANKOcCGAL. TRENCH WIDTH } 6r ROCK DEPTH24" LINEAR FT. 3 OTHER As btctcd ht i5A Nu accepted Systems may a's ba it�2:� REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT Tc Lo er 5rtt-/ S --e icy' C r -t u431 b H 4 K �l/�G``�fc� 4:fw Cj FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT ✓ �r , ��% r� SYSTEM INSTALLED BY .�'-^� ` � / ,�� . , " f_ fir,• -r , ! a /" .'�J. { .... /�w� 4; it (! f 3 ` `' OPERATION PERMIT BY: AUTHORIZATION NO. ' . ,r' `rr-- `.. I , DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMELJANCE. WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY -BETAKEN AS A 101 GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. --4- DCHD 02/02 (Revised) ;)'ermlliee s DAVIE COUNTY HEALTH DEPARTMENT' Name A ' i ` ` + ` c'°i f { Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions tar property: Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 4 Section: Lot: AUTHORIZATION FOR ti f`1' WASTEWATER Tax Office PIN:# d) f,ff I _ rj / _ f r' ,W j SYSTEM CONSTRUCTION AUTHORIZATION NO: 003030 A Road Name: f `. ` '; �. f_. r_ ,-I 4- ip: ✓ `~` �i..'v **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 Fonn/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 t + °•' , ^ •fir -E �) " f IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE -� # BEDROOMS i # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No U r t1 LOT SIZE TYPE WATER SUPPLY(` DESIGN WASTEWATER FLOW (GPD) NEW SITE R PAIR SITEr SYSTEM SPECIFICATIONS: TANK SIZE _GAL., PUMP TANKGAL. TRENCH WIDTH �! ROCK DEPTH LINEAR FP. D OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT .,� .t,'.! ,�.a k ` t t• 'l(ri111 %e fCl,rlr✓1� (.t1G/ � �1 i � !Lr lkvee-( << C i L` F — IIFOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. E OPERATION PERMIT r' * �/'' SYSTEM INSTALLED BY: �' ' f ' { • f Y r , 1` Ir 71 77, _ ,fir '> r•r AUTHORIZATION NO.' ( —OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMP�,J&NCE . WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO VAY BE'mfAiCEN AS Ad GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME., DCHD 02/02 (Revised) r � r .,_ Davie County Health Department D (� 'k� Environmental Health Section 11— rn r 4 P.O. Box 848 210 Hospital Street,k Courier # : 09-40-06u ENV1R . NTAL HEgtl,�;W Mocksville, NC 27028 oA Phone: (336) -753-6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection �n Name: '� i -L ,� '-,' T ' : Phone Number f �� `T 1- %��L J (Home) Mailing Address: W2 S (? t_'J =��7�-7 iJ ^ (Work) Detailed Directions To Site: lq&v 31 Property Address: 1 S' u s .� i AAuz Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: ' ,4 M 04 z- ,, - C Type Of Facility: J �,X r`i` L Date System Installed (Month/Date/Year): Z//2 /o3 Number Of Bedrooms:­j/Number Of People:_ Is The Facility Currently Vacant? Yes f4 ) If Yes, For How Long? Any Known Problems? Yes �N� If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: �_—. Number Of Bedrooms:Aumber of People Requested By: Date Requested: For Environmental Health Office Use Only A roved `Disannroved _ y� r Comments: PU 42 P Q O 3 O 3 -f: ►n v► a Environmental Health Specialist Date: 4/ % _ / *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash e �e Money Order # U 6 f" Amount:$ Date: 40—/,T /o Paid By: 44ea„ )40 Received By: Account #: ,5'��� Invoice #:2 84 r- shpt.-- D '� 1110"t 0 w , DAVIE COUNTY HEALTH DEPARTMENT { Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: r-aciuty: Kesiaence ATC Number: 3256 Pj q., i i. o z Tax PIN/EH #: 5861-59-5239.31S Subdivision Info: Redland Lot # 31 Location/Address: Highway 158-27006 rrvperny oizu: see Idp AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE O STRRUUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .19 `Sewage Treatment and Disposal Systems," but shall in N ' terr/Ql function satisfactorily for any given period of time. w Z� /0'5 /GSA 3J. FEF Septic System Installed By: Environmental Health Specialist's Signature : ,C yam/ / Date: ' DCHD 05/99 (Revised) :.U'. .^. .... l::• }. \ ..... .. .�.i •;�L , \ I tt.. !rr............... ............. 'a..........•'a^ tir ai • :. I 7 l J F {4S;' } ...:rifer,>,}..... - �` • ' � � r _I } 1 ^... .. was to to amr CSX 1}' ;;: ::; ., :?j•Y 'r Q ;: •1: •. J1J:. 3 ti Jt:.t•::JJ• . A rho I /: r r - KAYW cult MOT1. y Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Pj q.,17. o z Tax PIN/EH #: 5861-59-5239.31S Subdivision Info: Redland Lot # 31 Location/Address: Highway 158-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3256 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE O ST;UCTION IS VALID FOR A PERIOD OF FFIV'E YEARS. Environmental Health Specialist's Signature: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .19 `Sewage Treatment and Disposal Systems," but shall in N terr(Q function satisfactorily for any given period of time. lc -sr FIFJ i0 3� Septic System Installed By:Y Q Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: Proposed Facility: Residence DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street �� q' Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5861-59-5239.31S Subdivision Info: Redland Lot # 31 Location/Address: Highway 158-27006 Property Size: see map ATC Number: 3256 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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). THIS PERMIT IS SUBJECT TO REVOCATION ]I SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms #Baths 2 Dishwasher Garbage Disposal,; Washing Machine Basement w/Plumbing�aO Basement/No Plumbing: EI Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: EI Lot Size Type Water Supply _ Design Wastewater Flow (GPD) Site: New„pe Repair El System Specifications: Tank Size/,��OGAL. Pump Tank /,Q&GAL. Trench Width,` Rock Depth �� Linear Ft� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) IF 6 ” BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 pan. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** ,/74// Oeo � ,6f X62, "'re b qAs, Environmental Health Specialist's Signature: ') Date: DCHD 05/99 (Revised) FROM SAMNAZ,_INC. •►:�H�6~2U d2 09:S2a FAX NO. : 336 774 8701 davie county envhealth Aug. 20 2002 02:54PM P3 336 751 9786 p'2 AMIL1tATION MR SITE MI.UMIONJIMPROVEAtI.NI Pf:1tl V dr All,: Davie County Health Depaninent EntrirwMent'allfealth Section P.U. Box 648/210 Hospital Street lsockwille, LIC 210213 (336)751--Q760 ��*_MPoltT�tAtT'+• TiiIs AP?L2 CATION GtNNt7l 9B PROCZ:SSED UtJIXS9 ALL THE R>:QUIRED�-�� INFORhOtTYON ZS PROVIDED, Refer to tbu SNFOMCkTION DVLL:.TTW for ilzatruCtion_. 1. H:Wo to tw Billcct btA1( ^ Z � _ _ Cunract ftr$:*n Mailing Addavoo �r� �w 1�% (�`.�tj _ Aoetw Pnono Pusinoss Dhono 2. Nome on Porwit/A:C if Diffetwit Cheri ltbove Malls q hellmso _ rr.. city/stat?/zip J. r+ppl3Cation For: 47rSlte ZValuation tt Improvement Permit/ATC IJ Both �. 6ytf GOu to Sc. �iC4: �� .fOt:50 l'lc+Ji.le Home U Bu,^.iness M !"cluct.ty L: Other 5. If Residence: - 'i People A Bedroemr'� M bathroot:ts � t' iahreehrr IJ�eb:ge Diapoaal r i Wrts*.ing 1L^elai ie Ft�ti�temw�t/PI+u>li_nq t l 8asgmpnt/Ni PluS7,. rfj 6. if DValn@sD/Z.'ktorte.q'/Other: Specicy ry1,o / Fvople r sins �_� s cuorodes I showers A Vrinals if water Coolc-ate IF FOODSERVICE N Soar t3timat0d Water U*ace tgillcns po= day? 7. Type of vator supply: -e'Lcunty/City fl Nell IJ community a. Do you snticipalc additions ar expansions of the facility this system .s intenrJed to serve? ,'i Yea r► Nu ir)m what type? 1.64*iAfrw?7A1vr— CW e.!'rFSM6:Sf'COMPI.L•rc. wE REQUIRCDPROPER"l-Y INFORmAVOIC kEQt;1_S*1'l;0 IIMOIN'. I:illtcraPLA7orSITl:rlrtitll�JUSTCCstiIIMITiCDbywccNcot w.itllTItlSAPPLICATION. III uprrty Dimensions: ,j2�?� > a -X 16�4�3`f 3 WRITLr DIRE(MONS (ftrotn Muctisville) to 1.1tollial'IN: j •ra, air« rlrv: 4_ Property Address: Road Dame K , le e G 1 C4/Lip If in 2 Subtliv�ision� provide information, as follows: scctiuo: ` _ Block: Lor. `3-L Date Property Flagged: __ ls—�Lb-7­ This 4 to certify 11121 file information provided is correct to cite bext ortny knowledge. i t ndcrstantl that any pernngs) issued hereafter are subject to suspension or revocation, if the site plaits or intendett use change. or if lite infortualint, submilted it, ibis application is falsified or changed !, n/sr,, rur,(tsrrnrrlr/ia//u,i: w.�nnn.+iiilcJvro//cr,rrrgc.+ incurrrrl%n,rn //risapjdiewiuu. t, Hereby, give consent to the Au(ht-rircd Representative orne: G1vic Count, Flrattit De-Ixtrintrtt to enter upon above described property located in Davie County and o%vnW br to conduct A[ tcsti.tgl-roccduresAs neceyswry to rteterniine lite site suilabilily. OATF,, Z J 31GtNATLRfr THIS ARRA MAY HE USED FOR DRAWING YOUR SITE PLATY (Include all u t is and pivpostd properly Cncsinddimensloas, structures, st:tbacks, aodseptic locations}. Site I%evillt Cluirge ] 1.• f� 1 1� V �J APPLICATION FOR SITE EVALUATION/IhIPROVEAIENT PERMIT 'r2' Davie County Health Department ti/ ED Environmental Health Section P.O. Box 848/210 Hospital Street AUG 1 6 2002 Mocksville, NC 27028 (336)751-876.0 ENVIRONMEIVTALIIEALTH DAVIE GOIIN1y ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Ifl /Y-v/A) Z Contact Person w(� ✓� Mailing Address cot4 e' y CL, 'r, Home Phone ¢ City/State/ZIP 1 JU S r -a,•) Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation-WImprovement Permit/ATC II Both 4. system to service: 041ouse ❑ Mobile Home El Business CI Industry I_I Other 5. If Residence: It People It Bedrooms # Bathrooms II Dishwasher 1.1 Garbage Disposal II Washing Machine 11 Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes I) Showers # Urinals It Water Coolers IF FOODSERVICE: II Seats Estimated Water Usage (gallons par day) 7. Type of water supply: County/City ❑ Well I7 Community ©. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes a - Ko Ifyes, what type? ***I4IP0R7ANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client wilh THIS APPLICATION. Property Dimensions: :54Pe to C Tax Office PIN: Property Address: Road Name S City/zip If in a Subdivision provide information, as follows: Name: <-�Q 1`44-4 Section: Block: Lot: WRITE DIRECTIONS (from Nlocksvillc) to I'RUI'I?It'I'1': t" e r�o Pt' -'t, J Date Property flagged:�-- "1'Ilis is to certify that the information provided is correct to the best of my knowledge. I understand that any pernlil(s) issued hereafter arc 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 ann responsiblefor all charges incurred.lrunr this application. 1, hereby, give consent to the Authorized Representative of the Davie County l lcalth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed properly lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) F� S)7iJ LD Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. 5-5 Invoice No. 3/,;P-- APi'UCAIION fOil SITE EVALUAIION/ IMPROVEMENT PERM & ATC Davie County Health Department EnWronmenln/Health SeWon P.O. Box 848/210 Hospital Street Mockaville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCZSSBD UNLESS ALL T INIMRMATION IS PROVIDED. Refer to the INMRMATION BULLETIN for i _I - I . / 1 1. Nana to be Billed I i r /1011tJ IrVA0L Lo Contact Parson Mailing Addreaa h1"2 Rose Phone '%G City/state/EIP / u/Yc , . e. - Busin.ss Phone 2. Name on Permit/ATC if Different than Above I � I JUN t 4 RE D t=ct'BNMF_N UAVILC Njy' Mailing Address City/state/Zip ©/ 3. Application For: "Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to aervicas O"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People ! Bedrooms 1 Bathrooms 0 Dishwasher a Garbage Disposal 0 washing Machine ❑ Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/Othart Specify type E People / Sinks i Commodes i Showers + Urinals 1 Water Coolers IS rOODSERVICE: # Seats Estimated hater Usage (gallons per day) 7. Type of water supply: 9--County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes ❑ No If yes, what type? I"hIMPORTANTP" CLIENTS MUST CiOMPLETETII E REQUIRED PROPERTY INFORMATION REQUESTED I BELOW. Either a PLAT or SITE PLAN MUST BE SUBA117TF-D by the client with THIS APPLICATION. Property Dimensions: %J. YC� S 4 -- WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 57" f —59 •— 5�23' Z;d54 PrI004 Ll qv- - Property Address: Road Name City/Ztp ntA14r✓ee' /V -(f "9 If in a Subdivision provide Information, as follows: IA- — D -7—L,91 Name: `( /.- _ Section: Block: Lot: 3 Date Property Flagged: This Is to certify that the information provided b 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 to conduct all testing procedures as necessary to determine the site suits ility. DATE `1`!J/SIGNATURE / - - -- THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includ all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and peptic locations). k Site Revisit Charge Date(s): Client Notification Date: I EHS: Account No. 13 Revised DCIID (07/99) Invoice No. APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Account #: 989900136 Billed To: Westview Development Co. Reference Name: Proposed Facility: Residence Property Size: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5861-59-5239.31 Subdivision Info: Redland Lot # 31 Location/Address: USHighway 158-27028 see map Date Evaluated: 7 I3lo 1l' - Jz Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope % 47v S HORIZON I DEPTH 0 - _ 7_0 I Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence rr $ Structure Mineralogy` • HORIZON III DEPTH Texture group Consistence Structure Mineralogy� HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE O, _ SITE CLASSIFICATION: Ql�' 2A C41, LONG-TERM ACCEPTANCE RATE: ©% JJ 7. REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very 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 SC - 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 05/99 (Revised)