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359-371 Swicegood Street Lots 18A & 18BFOR WASTEWATER SYSTEM CONSTRUCTION must lie obtained from'tlris Department prior to the m ioof a system or the issuance of a building pernut n'n'nL__.__non.�.vt ._._._.__o,._._�_, o__..__ inns o_......,,.me.........._.....a'n.,.........t c..::•e....,� i.l ` �;)' Davie County Health Department I ', �ti IPn H `I/ .I Envfivnmenfa/Hea/HiSewon P.O. Boa 848/210 Hospital street uu NOV 2 5 1998 Mock(336)7, HC 27028 (336)7L� ! 51-8760 ENVIRONMENTAL HEAL] i••Z�ORTAN'PMe• THIS APPLICATION DAVIE COUNTY ' ffi" PHOCE3SED UNLE39 ALL THE REQUIRED INFORMATION IIS pgpylDLrp, Refer to the nUU*aTION BULLETIN for instructions. 1. Ham to be Billed 1 contact Person E7 Hailing Address Boma Phone City/State/LIP Business Phone Z• Hama on Pers,li/111'C It Different them Above "— Hailin Wailing Addeess 2A -!„a / city/state/rip _ f. 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC � th e' System to Bervice: ❑ House %la'ile Rome ❑ Business ❑ Industry ❑ other s. If Aesidencel , I People f Bedrooms a Bathrooms _2,- 0 Dishwasher n subage Disposal 0 Hashing Machine D Basement/Plnebinq O Basement/Ho P1mb1nQ 6. If Business/Industry/other: specify two ! People / Sinks f Commodes / Showers - tl urinals ! •Hater Coolers IF FOODSERVICE: /Seats Estimated Nater Usage (gallons per day) 7. Type of Ovate= supply: J*-C'0nni3r/Cit3r 8v it e ❑ Community s. Do you anticipa! i le additions or expansions of the facility this system is Intended to serve! ❑ yp 11 No if yes, what type!. "•'/MPORTANP**CLIENTS AIUSTCOMPLETE7M REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIJUSTRESUBMIZTEDby the client with THIS APPLICATION. Properly Dimensions: Sp WRITE DIRECTIONS (from MockrAlle) to PROPERTY: Tax Office PIN: 57�- (� — jay a�gA)� p� s®�S Properly Address:: Road NameStI rn 116 7`' lQ J � 0,, r.+lice4< City/Zip IN Yn go L If in a Subdivision' provide information, as follows: 19 7L Name: Section: Block: Lot: I Date ProDertv Flapped! This is to certify that the information provided is correct to the best of my knowledge, I understand that any permil(s) Issued hereafter are'subject to suspension or revocation, if the site plans or intended use change, or if the information submitted to this application is falsiRed or changed. 1, also, asdnstoad that! aur responsible for all charges incurred frons this WUoa *m I, hereby, give consent to the Authorized Representative of the D&* County Health Department, to enter upon above described property located In Davie County and owned by /) l9 q 2y — f — < to conduct all testing procedures as necessary to determine We site alta li rn 1� ac� DATE JF 9 SIGNATURE _ 7f2o �n J. fin & _ THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (includdfdl of the Property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Y Existing and proposed Account No. a Invoice No. �i� -- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT17—# Soil/Site Evaluation Water Supply: On -Site Well Evaluation By: 1 Auger Boring DATE EVALUATED Z I3t) q b PROPERTY SIZE S. o S'} QrC. ROAD NAME 5WI&t�C1000 ST— Community Public ✓ Pit Cut FACTORS 2-' 1 3 4- 5 6 7 Landscape position Slope % HORIZON I DEPTH - Texture groupGL Consistence G� S Structure Ic Mineralogy HORIZON H DEPTH . Texture group iviq (C�2 Consistence t u Structure Mineralogyl ` HORIZON III DEPTH - Texture group iG } Consistence r Structure Mineralogyt ; HORIZON IV DEPTH Texture group Consistence. Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE a. CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: - ! EVALUATION BY: LONG-TERM ACCEPTANCE RATE: b" OTHER(S) PRESENT: REMARKS: LEGEND 'Landscape Position I 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 j 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 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 i 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 : DcxD(oi-so) ii■ ii ■■■■EME MOMMEM■ o■e■eM■ ■■e■o■■ ..«uu..nvn run arrt ty'"A11UN/IMPROMAENT PERMIT & ATC Davie County Health Department �/ J Environmental Health S&WOH P.O. Box 848/210 Hospital Street Mockaville, NC 27028 NOV 2 5 1998 (336)751-8760 ***ZHPORTANT***ENVIRONMENTAL HEALTH THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL AEQOI INFORMATION I3 PROVIDED. Refer to'- the INFORMATION'SULLETIN for instructions. 1. Name to be Billed Nailing Address CSty/state/ZIP a. Name on permit/ATC if Different than Marling Address'i�-1 3. Application For: ❑ Site Evaluation e., ,system to service; ❑ House WFfobile Home s. If Residence: # People n Dishwasher 0 Garbage Disposal Contact person Game Phone 9JIDI City/state/Zip ❑ Improvement Permit/ATC th ❑ Business ❑ Industry ❑ other # Bedrooms -? i Bathrooms -2- 0 2 0 mashing Machine S. If Dearness/Industry/other: specify type 0 Basement/Planbing 0 Basement/No Plumbing # people i Sinks # Commodes # Showers # urinals # mater Coolers IF FOODSERVICE: T Seats Estimated Water Usage (gallons ` � per day) ! C u 7. Type of water supply: nty/City an e,11 ❑ Comnwnity e. , Do you anticipate additions or expansions of the facility this system is intended to serve! ❑ Yes 0 No U yes, what type' ***IMPORTANT*** CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a IAT or SHITE PLAN AIUST BESUBMITTED by the client with THIS APPLICATION Property Dimensions: _ 11-4�� //� .0 5� % �/J / QR VIR91 DIRECTIONS (from Moccljaville)/to(PROPERTY: Tax Office PIN: # Property Address: Road Name 1` St �lr) Ilei YD /e P Gy-� City/zip ee171e If in a Subdivision provide information, as. follows: °� ��/� Name: Q- U"YII:D )— Section Block: Lot: Is( fI Date Property Flagged: // -- ,- q aJ 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 chauged. 1, also, understand that I am respossale for all charges incurred from this appUcadom I, hereby, give consent to the Authorized Representative of the Dav yyCounty Health Department to enter upon above described property located in Davie County and owned by F) o o ev to conduct all testing procedures as necessary to determine the site suita li DATE / f —y SIGNATURE 1!L[�1p/J r✓I / 1- �� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includdill of the folloAng: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). :x Account No. 2 Revised DCHD (07/98) Invoice No. df6o, 8 54IiAVIE TMPRl 'L:. rjLL k, ., 1 - ***NOTICE***.TTUS PERMIT IS SURIECYTO REVOCATION IF IV #BATHS "72---, 4666UPANTS GARBAGE DISPOSAL., Yes 'ATION; BUILDING.TYPE :f: if BEDROOMS �� q�o r Sjm .TEM SPECIFICAT i DAVIE COUNTY HEALTH DEPARTMENT L . 'Envitonmental Health Section SECTION LOT18 3 Soil/Site Evaluation APPLICANT'S NAME ��d /t t'^^ J DATE EVALUATED PROPOSED FACILITY M � PROPERTY SIZE �S•D 5 �I' A'�-- SUBDIVISION ROAD NAME �uJlCf�xbO S� Water Supply: j On -Site Well Community Public Evaluation By: Auger Boring Pit Cut - FACTORS 01- at 3 4. 5 6 7 Landscape position L - L Slope % HORIZON I DEPTH Texture groupGL G� Consistence Structure . Mineralogy.` HORIZON II DEPTH - 2 4-2,44 Texture group Consistence S Structure k - Mineralogy 1. HORIZON IH DEPTH .� . Texture group Consistence ir Fr S Structure : k '50k - Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON - - SAPROLITE CLASSIFICATION. LONG-TERM ACCEPTANCE RATE C I SITE CLASSIFICATION> S EVALUATION BY: -,7"n LONG-TERM ACCEPTANCE RATE: 7 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 plainH.- Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI -Sift SICL - Silty clay loam SIL -Silty loam , CL -.Clay loam SCL - Sandy clay loam SC -Sandy clay SIC - Silty clay. C - Clay CONSISTENCE ' � Mois • 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 tructure SC - Single grain M - Massive CR - Crumb GR - Granular AB - 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 jRestrictive 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 -tern acceptance rate - gal/day/ft2 DCHD (0690) *,*NOTE** This Authorization for Wastewau to issuance of any Building-P.ermi Office when applying for Buildm; .(In comphance; with Article I I of 0: $', Chapte w� I ENVrRONM PLH ALTHSPECIAtrST;; ,+D, :r System Constriction MUST BE ISSUED by the Davie County Environmental Health Section prior Ls: This Fomi/Authorization Number should be presented to the Davie County Building Inspections . Permits r I30A; Wastewater systems; Secnon 1000.Sewage Treatment and Disposal Systems) t) ***NOTICE**.* THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION Z d 19 VALID FOR A PERIOD OF FIVE YEARS 1TE ISSUED ME ME No No