387-409 Swicegood Street Lots 17A & 17B-ovement Pemut, DOES NOT. authorize the b6nstrd6flofi or installation of a septic tank system or anywastewater system An
tIZATION FOR WASTEWATER SYSTEM CONSTRUCT1ONmust be obtained from this Departrnent prior to the
oWinstallauon of a system or the issuance of a building pemut
Acl'e"11 of G.S.Chapter 130A; Wastewater Systems, Secnon 1900 Sewage Treatment and Disposal Systems)
DCHn 03/96 (Beviud)
i
i
.....e..e aneo r , �{ (
epartment
I
Davie County Health DD
EaVIM17menfaff/ealfbSeWon �� i -{ Z�4e
P.O. Box 848/210 Hospital Street ILIIIUI NOV 25 1998
Mccksville, HC 27028
13361751-8760
***XWORT�*• ENVIRONMENTALIO
TH23 APPLICATION CApNpT BE pgp�.g�D UNLE33 ALL THE RE
INFORMATIONQUIRED
I9 PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
i
I. Name to be Billed
Nailing Addeess
City/state/EIP
2. Nass on Petah/ATC if Different than AbWe�
Nailing Address5
Ag" / -
3. Application For: 11 Site Evaluation
4. Bystem to service: D House 9110 -bile Home
s. It Residence: IF People
11 Dishwasher 0 Garbage Disposal
contact Person
Boma Phone
1)1y- Business
City/state/Lip
D Improvement Permit/ATC th
D Business ❑ Industry ❑ Other
4 Bedrooms_ f Bathrooms 2._
D washing Machine
6. If Business/Industry/other: Specify type
4 Canwded f Showers
IF FOODSERVICE: d Seats
7. Typo of water supply:
D aasenmt/Plumbing D Basement/Mo Plunbing
/ People 4 sinks
4.urinals 0 Mater coolers
Estimated stater Usage (gallons per day)
S�County/City w ell D Community
e. Do you anticipate additions° or expansions of the facility this system is intended to serve! ❑Yea D No
If yes, what type!
-''IMADRTANP** CLIENTSAlUSrCOMPLETETHE REQUiREOPROPERTYINFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN Anrer nr ct.nm,,w .,...__ ..
Property Dimensions: S. O WRITE DIRECTIONS (from Mocluville) to PROPERTY:
Tax Office PlN:R�Dl7p�,S 7 �Q/S
Properly Address: Road Name �' St � le � 0o
SN/1CB4UC�
City/Zip EQ1171 Lo C� , 1>
If in a Subdivision provide Informallon, as follows: 14
7!'
Name: -),(Il Iy r—
Section: Block• IAI:�
Dale Property Flagged:
This Is to certify that the Information provided is correct to the best of my knowledge I understand that any permtl(s)
Issued hereafter are subject to suspension or revocation, If the site plane or intended use change, or if the information
submitted In this appllcalion Is falsified or change(L I, also, understand that f ant respotldblefor all charges incurredfrane
thisWUcadam I, hereby, give consent to the Authorized Representative of the Da* County Health Peparim ea
to enter upon above described property located in Davie County and owned by rr
to conduct all testing procedures as necessary to determine the site suits It ,= �ar) S
DATE — 9 SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includdill of the
Property linea and dimensions, structures, setbacks, and septic locations).
1�
10--->
Revised DCHD (07/98)
Existing and proposed
Account No.
invoice No. /
` , • - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOTS
Soil/Site Evaluation
APPLICANT'S NAME •.L(OL�/ d' IUa �a� DATE EVALUATED
PROPOSED FACILITY: Yfl7" PROPERTY SIZE $• D
SUBDIVISION ROAD NAME 45t.51��
Water Supply: On -Site Well Community Public
Evaluation By: I Auger Boring Pit Cut
SITE CLASSIFICATION: YZ 2 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 64 OTHER(S) PRESENT: �/y"
REMARKS:.
LEGEND
1 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 -,Silo
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
I SC - Single grain M - Massive CR - Crumb GR - Granular. ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
' Mineraloav
11:1, 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(01-90)
ROR WIN 1055 R.
Consistence
•:
��®lam®®e®®
121.
Consistence
HORIZON
—�o--®�
•
®®®®moo®
SITE CLASSIFICATION: YZ 2 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 64 OTHER(S) PRESENT: �/y"
REMARKS:.
LEGEND
1 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 -,Silo
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
I SC - Single grain M - Massive CR - Crumb GR - Granular. ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
' Mineraloav
11:1, 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(01-90)
ii
■■■■■■■
■■■■■■o
■o■oe■■
ME
F.. ,2.6
;AUT,EacORIZATION NO: 18'6 7 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section i , ` PROPERTY INFORMATION .
Permittees + P.O. Box 848
Name: �C� �t�, tUa �e t. ^ IUL" 4iIo\ cksville, NC 27028 Subdivision Name:
Phone ti 336-751-8760
Direcnons to property: ' rad l s 7D �DiS ' . • Section: 'Lot:
�TdQ�.lJ pni t[JIGcGGo/iC—s'"AuWAASTTEWATEROR
SYSTEM CONSTRUCTION Tax Office PIN:# ,l
Road Name. SLJIGeIsGn�Silip;. 2%z
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
.to issuance of any -Building-Pemtits: This Forrn/Authorization Number should be presented to the Davie County Building Inspections.:.
Office when applying for Building Permits.
(In complianceith Article hof G.S. Chapter 130A Wastewater Systems, Section . ] 900Sewage Treatment and Disposal Systems)
(!7
�- J ***NOTICE***. THIS AUTHORIZATION FOR WASTEWATER C(
-fid- - : ASUED
IS VALID FOR A PERIODOF.FIVE YEARS.',
ENVIRON ALHEALT SP ALIST
DCID05)96(RcviW)
Davie County Healih Department ••
' Environmenfa/Health Se cHon rLNOV62
P.O. Box 848/210 Hospital StreeMookaville, HC 27026
(336)751-8760 5 1998
*ssIFMORTAHT's*• TNI9 APPLICATION CAIOYOTBffi FIWCBSSZD MURSS ALL THE AE OIREttVIECOUNT!
nmop ATION ,Is PRMDED. Refer to the INFORMATION BOLLETIN for irla IREQUIRMV
1, nam to be Billed ` t
Contac t Person tt� Nailing address
Home Phone �
city/state/zIP
Business Phone L %
a. Name on Perslt/a'rC If Different than above � �f-+f�
— Jfoeo� �oc�viti iiLh
dC� Soh,
Nailing address
----------ii city/state/zip -5
3. APplication For: U Site Evaluation
� �� ❑Improvement Permit/ATC 6th
a' system to earvlee: ❑ House 9'Robile Home ❑ Business ❑ Industry ❑ Other
a. If Residence:I E People _
i Bedrooms # Bathrooms _ ,
D Dishwasher D Garbage Disposal D Washing Machine D Bagsemmt/Plumbing D Basement/Ho Plumbing
6. I! 8nsiness/Industry/other: specify type
f People / Sinks
Ii Commodes / showers
f Urinals f nater Coolers
IF FOODSERVICE; ;Seats Estimated Hater usage (gallons Per da t
Y
7. Type of water supply: runty/city [SFA 11
e 11 Community
e. Do you anticipate addition; or expansions of the facility this system is Intended to Serve! ❑ Yes ❑ No
If yes, what type.*
i
""'1MPORTANT'••CLIENTS AIUSTCOAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN A/UST BESUBM TIED h the client with THIS APPLICATION.
Property Dimensions: W�/RITE DIRECTIONS (from MOckkssVille) to PROPERTY:
Tax Office PIN: '. # ) / � �— lq "R/�%� 0 S 78'O ®/ [,
Property Address: Road Name % I rn I ie, Ze F-/- `ioJi 0
du77-
City/Zip EQ )-A C S'
If in a Subdivision provide information, as follows:
Name: _ -1,(1116 t✓
Section: Block: Lot:I � 3 Date Property Flagged: ;Z
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 plana or intended use change, or if the inrormallon
submitted in this application is falsified or changed. 1, afro, xnAn tandthat 1 am rrsparuglejor all charges lscarred &M
this appllcadom 1, hereby, give consent to the Authorized Representative of the DavjgCDunty Health Department,
to enter upon above described property located in Davie County and owned by f 1,
to conduct all testing procedures as necessary to determine the site sulfa li �) -
DATE SIGNATURE
THIS AREA MAY BIE USED FOR DRAWING YOUR SITE PLAN (Induct 1 of the folio lug: Existing and proposed
property lines and dimensions, structures, Setbacks, and septic locations).
Revised DCHD
Account Na
e Invoice Na
Winer Supply: I On -Site Well Community
Evaluation By: Auger Boring Pit --
Public
Cut
SITE CLASSIFICATION: Ps EVALUATION BY:
/�/�
LONG-TERM ACCEPTANCE RATE: O. 1 OTHER(S) PRESENT:
REMARKS:
Ra Rid ape Pos L - Linear LEGEND
tion
Ridge - Shoulder 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
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
iNP - 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 (01-0) _ _ -
Consistence
• REMOT3
�
• •
a�®ate®�
SITE CLASSIFICATION: Ps EVALUATION BY:
/�/�
LONG-TERM ACCEPTANCE RATE: O. 1 OTHER(S) PRESENT:
REMARKS:
Ra Rid ape Pos L - Linear LEGEND
tion
Ridge - Shoulder 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
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
iNP - 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 (01-0) _ _ -