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406-418 Swicegood Street Lots 7A & 7B? ,I ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION - ti^ 17) ISVALIDFORAFERIODOFFIVEYEARS i .ENVIR N NT AL HEALTHS.ECI ST DATE.1 SUE DCHD 05/96 (Revised) Davie County Health De patiment �� V Eav/tvamentalHeamiseemon � r P.O. Box 848/210 Hospital Street D Mockaville, HC 27028 51998(336)751-8760 NE2 ***1!H'ORTANT*** THIS APPLICATION CRHNOT M pRpCEBSED INFORMATION IS PROVIDED. Refer to the UNLESS ALL THE REQ VIE COUNTY 1NFORMATION BULLETIN for ins ons. 3. name to be Billed Contact pars..Q Mailinq address - nnn some phone Clty/state/SIP 1 Business Phone 2. Name on Peaslt/ATC If Different than Above__ -IS Mailing Address �A-i..- ! 3. Application For: ❑ Site Evaluation 4' System to servlae: ❑ House ld-Mobile Home s. If Residence: I People D Dishwasher D Garbage Disposal Q �EUs). City/state/Sip ❑ Improvement Permit/ATC th ❑ Business ❑ Industry ❑ other I Bedrooms i Bathrooms _� ❑ Bashing Machine s. If Dnsiness/Industry/ether: specify type I Commodes f showers IF FOODSERVICE.- M Seats 7. Type of Mater sopply: ❑ Basement/Plusbing I People I urinals ❑ Basement/No Plusbing I sinks / nater Coolers Estimated Water `Usaag'e (gallons per day) �ounty/City hell ❑ Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑ Yes ❑ No If yes, what type! ***IMPORTANT*** CLIENTS MUST coAfPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITEPLA�N�MUST RESUBMITTED b the client with THIS APPLICATION. Property Dimensions: o S S WRITE DIRECTIONS (from Mocluvllle) to PROPERTY: Tax OtlicePIN:M dol S 4 Property Address: Road Name o' Sty—% Zo A/ -C9, C, . iu/ic z yo c City/TJp EQ)71 Q 5• If in a Subdivision provide Informal a, as follows. Name:7.(1 Section: Block: Lot:—I-&—Date Property Flagged: %% g.6' Zj7 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. 1, also, understand that I am rrspons9le for all charges Incarred from this appUcatiom 1, hereby, give consent to the Authorized Representative of the Da* County Health BerrlmeDf, to enter upon above described property located in Davie County and owned by i} py ev- — f I S to conduct all testing procedures as necessary to determine the site suits li rn DATE Lj 9 SIGNATURE W��n J'pn ///-, THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includdfll of the Property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) w Existing and proposed = X Account No. s' Invoice No. 9� • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT- Soil/Site Evaluation APPLICANT'S NAME ' &LlA250-�lkY^Ar PROPOSED FACILITY 4-1' SUBDIVISION ' DATE EVALUATED 7 �0 PROPERTY SIZE .J • O S'3 Q e_ . ROAD NAME Wafer Supply: 1 On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE; O`I fly"` OTHER(S) PRESENT: C"Ir �^ Q REMARKS: LEGEND Landscape Position R - Ridge S - ShoulderL - 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 SII, - 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 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(01-90) HORIZONIDEPTH •_ ���®sem®® • - - • � �'��-®�-moi SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE; O`I fly"` OTHER(S) PRESENT: C"Ir �^ Q REMARKS: LEGEND Landscape Position R - Ridge S - ShoulderL - 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 SII, - 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 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(01-90) ■■■■ MEMO iim■ml MENU '. 1 $ 0 Q , :, DAVIE OUNTY I�EAL�TH DEPARTMENT r r IMPRO MENT AND OPERATION PERMITS . PROPERTY INFORMATION Perm e s Name (t �1 f Lh Subdivision Name Duecuons to property (+d. i 'it:. / �� Section Lot. IMPROVEMENT PERMIT Tax Office PIN#1 �� '�(a �2"�-`�� RoadName�h%GT^c c'�; 5�P'�%tJ�_'' *NOTE** Tlris Impr6Leinent pegnit DOES NOT. authorize the construction'or installation of a septic tank system or any wastewater system. An "AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department poor to the construcaon/i illation of a 'system or the issuance of a building pemuL (In compliance with Article l l of G.S: Chapter 130A; Wastewater Systems; Secuon 1900 Sewage Treatment and Disposal Systems) f ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE MENDED USE CHANGE YOUR WASTEWATER ONMENTAL HEALTH S� D ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE .; k INSTALLING THE SYSTEM r , . � # OCC_ ' e) RESIDENTTAL SPECIFICATION: BUILDING TYPE �� #BEDROOMS #BATHS 'UPANTS _GARBAGE DISPOSAL: Yes or o • COMMERCIAL SPECIFICATION FACILITY TYPE # PEOPLE _ # PEOPLEISHIFT� � # SEATS INDUSTRIAL WASTE Yes of No , LOT SIZE - TYPE, WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)�NEW SITE] �" ' REPAIR SITE - SYSTEM SPECIFICATIONS: TANK SIZE r.ciALr PUMP TANK - ` GAL. TRENCH W IDTIi ROCK DEPTH,_ LINEAR FT. -3� - :.; `, �. `, ..^-.� / •: Rork �, OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: INS"�ALL tJN GOtJyOs7��'iZl.d'� -� '�: �i0vt�4�'. IMPROVEMENT PERMIT LAYOUT t TFI -10 "i4Ntc 1S ,° j� Frzn�•r , a' .. **CONTACr'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. . .DCHD 05196 (Revised) - Davie county Healtit Department • �•�•�PJ /�S �N�V - Envitvnmenfa/Nea/bltSeWon ?' [y� 4� P.O.,Box 848/210 Hospital Street `~ Mockaville, NC 27028 0 43361751-8760 2 5 J ***DW0RTANT*** THIS APPLICATION CAMW IM PROCESSED UNLESS ALL THE REQUIRED w I I IIEALTH <, INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruation�N�N �„ 1. Nams'to be Billed 7 ` t contact Person 0 Mailing Address [1. Home Phone y� .,ally/state/ZIP Business Phone a. Name on vomit/ATC if Different than Above S��O' 0 Mailing Address _ S2¢j ! 3. Application For: 0 Site Evaluation 4. system W Service: D House 9 -1110 -bile Home a., If Residence:, /People �r 0 Dishwasher 0 Barba Disposal eposal city/state/Zip 0 Improvement Permit/ATC th 0 Business 0 Industry 0 Other i Bedrooms iBethree= U washing Machine 6. If Hn■lnes■/Indostry/other: Specify type / C°®°d°° 6 Showers IF FOODSERVICE: /Seats "'7. Type of Mater supply: 11 Basement/Plunbing If people i Urinals D Basement/No plumbing i Sinks i Nater Coolers Estimated Water Usage (gallons per day) FC�County/City rv'irell e. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, What type? 0 Community 0 Yes 0 No "**IMP0RTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESU ITTED b the client with THIS APPLICATION. Property Dimensions: DMECf10NS�(froom Moccksvfll�le)/to PROPERTY: Tax Oliice PIN: # S ' Property Address: Road Name i s1` /%I1//P. %D 4%ToJJVIce4v4 City/Zip ee Yn Lo C �. '• If in a Subdivision provide Informatio0, as follows: `•Name:(— Section Block: Let: % Date Property Flagged: 2z 67 �� 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 In this application is falsified or changed I, also, understand that i am wVamlhle for a/1 charres incun-ed fronr this appUcadom 1, hereby, give consent to the Authorized Representative of the Dsvk County Health Departmen to enter upon above described property located in Davie County and owned by _ f Jqyy — �,Jl go conduct III testing procedures as necessary to determine the site suits li DATE -- �_— SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN Property lines and dimensions, structures, setbacks, and septic loci Revised DCHD (07/98) of the fellojiiag: Existing and proposed Account No. Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Water Supply: Evaluation By: " On -Site Well Community_ Auger Boring Pit SECTION LOT l B DATE EVALUATED `Y �.. PROPERTY SIZE 3.O S ROAD NAME �Ll�l�li1 C�JtiBt1� Public.' WAN 1101 14 Consistence Consistence.®--�®®- Z4 Wil •' • ®�®ems®- ... 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 SII. - 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 - Vey 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 Mineraloev 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